^LIBRARY OF CONGRESS. # 

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I <%A*/i. "RCi.ofe I 

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UNITED STATES "UP AMERICA. ! 



TREATISE 



F E Y E R 



OR 



SELECTIONS FROM A COURSE OF LECTURES ON FEVER 



BEING PART OF A 



COURSE OF THEORY AND PRACTICE OF MEDICINE 



DELIVERED BY 

ROBERT D. LYONS, K.C.C., 

M.B.T. CD., L.K.Q.C.P.I., L.R.C.S.I., M.R.I. A., 

$f)2J5Utaix to 3ixbis-gtmt ^artfjutal ; 

FORMERLY CLINICAL ASSISTANT TO THE MEATH HOSPITAL ; 

PROFESSOR OF PRACTICE OF MEDICINE AND PATHOLOGY IN THE SCHOOL OF MEDICIN] 

OF THE CATHOLIC UNIVERSITY OF IRELAND J 

FOREIGN SECRETARY TO THE PATHOLOGICAL SOCIETY OF DUBLIN ; 

MEMBER OF THE ROYAL MEDICAL SOCIETY OF LISBON. 

LATE PATHOLOGIST-IN-CHIEF TO THE BRITISH ARMY IN THE CRIMEA. 

ETC. ETC. ETC. 




PHILADELPHIA: 

BLANCHARD AND LEA. 

1861. 









PHILADELPHIA: 
COLLINS, PRISTEB, 705 7AYHE STREET. 



TO THE 



RIGHT HONORABLE LORD HERBERT, OF LEA, 

AND TO 

SIR JAMES CLARK, BART., M.D., 

1 j$dfcgte t\n Wtfam, 

OUT OF RESPECT FOR THEIR EMINENT SERVICES TO THE CAUSE OF 

MEDICAL EDUCATION, 

AND IN ACKNOWLEDGMENT OF PERSONAL FAYORS. 

ROBEKT D. LYONS. 



PREFACE 



I am induced to publish this work on Fever, with a 
view to bring within the reach of the Student and Junior 
Practitioner, in a convenient form, the more recent results 
of inquiries into the Pathology and Therapeutics of this 
formidable class of diseases. 

The works of the great writers on Fever are so numer- 
ous, and in the present day are scattered through so 
many languages, that they are difficult of access, not only 
to students, but also to practitioners. I shall deem my- 
self fortunate if I can in any measure supply the want 
which is felt in this respect. 

As it would not be possible to embrace in a single 
volume all the varieties of Fever, I have thought it best 
to deal only with those forms of the disease which are of 
most practical importance. 



R. D. L. 



8 Merrion Square West, Dublin : 
December 27th, 1860. 



CONTENTS. 



Chap. 
I. General Observations 



II. General Pathology of Fever 

III. Classification of Fevers 

IV. Simple Continued Fevers . 
V. Varieties of Synochal Fever 

VI. Typhous Fevers ..... 

VII. Typhoid Fever 

VIII. Typhoid Fever of Crimea . 
IX. Yellow Fever . . . . . 
X. Pathological Anatomy of Yellow Fever 
XI. Yellow Fever of Lisbon 



Page 
IT 

34 

46 

54 

84 

95 

169 

223 

248 

293 

333 



Index 



351 



OUTLINES OF FEYEE 



CHAPTER I. 

GENERAL OBSERVATIONS. 

We commence to-day the study of the most remarkable and 
the most important class of diseases to which the human kind is 
liable. 

In its varied history, medicine presents nothing which more 
forcibly arrests our attention, than the great fever epidemics, no- 
tices of which are to be found in the records of all ages, and in 
the annals of every race and people. And when, as in more re- 
cent times especially, we are enabled to realize, by numerical 
estimate, a full and accurate conception of the vast extent to 
which fevers prevail in great epidemic visitations, it becomes 
evident that the study of this dire scourge of humanity, with a 
view to the possible mitigation of its ravages, constitutes a social 
as well as a medical problem of the highest importance. 

In all times we find the great masters of our art laboring assi- 
duously and devotedly in this grand work, the import of which 
they well knew — few in the present day better than Sydenham 
in the eighteenth century. 

If you desire to follow in their footsteps, you must emulate 
their learning and zeal, and their devotion to their art. And 
truly a great task lies before you, great in its purposes, noble in 
its ends. It ranks second to but one : that which ministers to 
the glory of our Maker. 

By far the most important of the duties to which you will be 
called, when you pass into the world as practising physicians, no 
matter in what clime your lot may be cast, will be those which 
will devolve on you in connection with the treatment of fevers. 
2 



18 OUTLINES OF FEVER. 

"Et profecto haud oscitanter impugnandum est hoc morborum 
tarn pestiferum agmen, quod nullo non die cum genere humano 
bellum gerit internecinum atque aanovhov et cujus telis duo ad 
minimum hominum trientes (si eos demas qui violentst, morte 
perimuntur), confossi quotannis occumbunt." 

In the words which I have here quoted from Sydenham, that 
great observer states, that excluding deaths from violence, fevers 
constitute nearly two-thirds of all the diseases by which mankind 
perishes annually. And I believe that this statement is hardly 
in any way to be regarded as an exaggeration for his day. It is 
not perhaps in the generations of men that pass silently away by 
disease, as it invades the homes of the poor year after year, that 
its effects are most terribly felt, and most strikingly manifested. 
It is in the midst of war's mingled triumphs and alarms, when 
the false pride, or the insulted honor of nations, or the love of 
conquest, pits against each other the flower of their youth on the 
battle-field, that disease, and pre-eminently febrile disease, makes 
its most deadly havoc. To take no other xample, I think I 
should be justified in saying that considerably more than half of 
the whole deaths of that splendid army of over 300,000 men which 
France supplied in the late Eussian war, was caused by fevers, or 
the diseases secondary to fevers. The whole of the French losses 
by injury and diseases in the Crimean campaign, may be taken 
at very close to 70,000 ; the report of the French Minister at 
War gives the numbers at 66,000. On the side of England 
10,000 men of the flower of the British army were carried off by 
disease in seven months, in the first winter's campaign in the 
Crimea. From the 1st September, 1854, to April, 1855, 4,228 
men perished from disease in the hospitals of Scutari alone, of 
whom but 359 died of wounds. Accurate figures are out of the 
question, and were unattainable even on the spot ; but from my 
own personal observation, I am induced to believe that an im- 
mense proportion of these deaths was the result of fever and the 
diseases secondary to fever. When dealing with the subject of 
typhus, I shall perhaps be induced to give you some brief his- 
toric notices of the great ravages committed within the present 
century, and at the close of the past, by the terrible fever epide- 
mic known as the Kriegs-pest, or war plague, and which, origi- 
nating in the great armies that then turned the plains of Europe 
into a series of vast slaughter-houses, continued to ravage camp 



MORTALITY FROM FEVER. 19 

and battle-field, cities and country districts, for many years sub- 
sequently. 

But if we want the most striking evidence from figures, of the 
terrible waste and destruction of life involved in great fever epi- 
demics, we need not go beyond the records of our own country, 
in which, for ages, the typhus has had its home. 

At no time, as it would seem, within the historic period in 
Ireland, has a century passed unmarked by one, or, it may have 
been, more visitations of this fatal pestilence, so long ineradicably 
domesticated amongst us. 

Since the national devastation which resulted from the pro- 
tracted and exhausting wars of the sixteenth and seventeenth 
centuries, the epidemic recurrence of fevers would seem to have 
assumed a more fixed and determined periodicity. Thus, for the 
last two hundred years, almost every quarter of a century has 
been signalized by a more or less fatal invasion of these diseases. 
Indeed, so nearly fixed and definable seem the laws which govern 
the movements of the great epidemics of this country, that we can 
almost with certainty predict their return, like that of some ill- 
omened meteor of the olden time. And experience of the past 
shows us, that it is far from an improbable prediction, that ere a 
score or two of years shall have passed over our heads, we may 
be again called upon to combat a pestilence as wide-spread and 
as fatal, as that which will ever make the last decades of our 
social history remarkable. Our own century has already wit- 
nessed not less than three epidemic visitations of first-class mag- 
nitude and fatality. 

Let us take a glance at the numerical results which the reports 
and investigations of the Census Commissioners of Ireland have 
brought to the illustration of this subject. You will see that it 
is not only in the last decade that fever has had a large share in 
raising the percentage of our mortality to an alarming height. 

According to the census of 1841, the total deaths from fever in 
the ten years then elapsed, or the decade 1831-1841, reached the 
enormous number of 112,072. 

Large, however, as these figures are, we find that they are all 
but doubled by those which represent the mortality, from fever 
alone, in the subsequent decade, that of 1841-1851. This period 
was, as you are all doubtless well aware, made remarkable by 
the terrible epidemics of 1847, 48, and 49. The number of deaths 



20 OUTLINES OF FEVER. 

from fever solely, for the whole ten-year interval, 1841-1851, 
amounts to no less than 222,029! And this return, you must 
bear in mind, takes no cognizance of the many thousands who 
perished by the wayside, or in the lone deserted cabin, untended 
and uncared for in the general moral prostration that paralyzed 
the sympathies as well as the energies of all. Thousands there 
were, as we all well know, who thus passed away uncounted and 
unrecorded, and whose deaths would swell the great mortuary 
roll of that decade, far beyond even its present terrifying propor- 
tions. Another great element is omitted, and necessarily so, from 
the calculations of the Census Commissioners ; I refer to the 
number of those who, in the general panic of emigration which 
then seized on so many thousands of our people, bore with them 
from their Irish homes the seeds of the pestilence, which ripened 
into fatal maturity, between the crowded and stifling decks of the 
emigrant ship, or upon the hospitable shores of the country of 
their adoption, carrying death and desolation to all with whom 
they held intercourse on their landing. 

But even if we confine ourselves to the consideration of the 
mortality from fever, as furnished by the census returns, what an 
awful subject for contemplation is there presented ! Again, what 
a fearful contingency is it not to anticipate, not only as possible, 
but as not improbable, that hundreds of thousands of the very 
flower of our race may be destined to fall victims to fresh visita- 
tion of this dire pestilence, ere the present quarter of a century 
shall have elapsed ! None can say that such will not be the case. 
Indeed, many are convinced, and I am not indisposed to share in 
the conviction ; and I would even venture to say, regardless of 
the fidvtt xaxZv ! which meets all such prophecies of ill omen, that 
as far as human experience goes, it is all but certain, that this 
century will not close without one, or it may be more, typhus 
epidemics, similar, if not superior in extent and malignity, to 
that from the dire effects of which we have but just recently 
emerged. 

Let us inquire what proportion this enormous number of deaths 
from fever bore to those from all other diseases. We find that 
during the past decade, 1841-51, the deaths from dysentery, 
though next in order, amounted to only 93,232. Thus the deaths 
from fever were more than double those from dysentery ; while 



FEVER ENDEMIC IN IRELAND. 21 

to the total specified causes, the deaths from fever were in the 
proportion of 1 to 5.5. 

Now, if the deaths from fever be assumed to be only as one to 
three of those affected with the disease, we should have the 
number of those attacked within the decade, greatly over half a 
million. More than one-sixteenth of the population would thus 
have gone through the epidemic. No such calculation can, of 
course, be accurate; but it will give you no unjust view of the 
enormous responsibilities, the duties, and the cares which devolve 
on those who constitute the -medical body in this country. In 
no way can you get a more full conception of the importance of 
the mission which they are called upon to fulfil. 

If you are destined to be practitioners in Ireland, certain I am 
that much of your practice will be in fever cases ; and that as 
fever patients, the highly prized lives of the lords of the soil, and 
in sight of God the not less prized lives of his poorer crea- 
tures, your own peasant fellow-countrymen, will again and again 
be in your hands : with what zeal and energy should you not 
prepare for these trusts ! 

But you must likewise remember that it is not alone in times 
of great epidemic visitations that you will have to combat this 
{i morhorum tarn pestiferum agmen" in this country. For I believe 
it admits of no doubt, that in its worst forms, the maculated 
typhus, or Irish typhus — for by this name it is now almost uni- 
versally known amongst European nosologists — is never, on any 
given day, in any given year, entirely absent from a greater or 
less extent of the city or country districts of Ireland. It is, in 
fact, and has long been endemic amongst us, in the fullest sense 
of the word. In the natural history of the disease, and as an 
appendage to any definitions of the typhus, systematic noso- 
graphers must henceforth add the words, u chief habitat, Ireland." 
As Irish practitioners, it will manifestly be your first and most 
essential duty to make yourselves masters of all that science 
furnishes to us respecting the pathology and therapeutics of 
fever. 

But even should your avocations be exercised in other lands, 
whether as public servants in any of the distant colonies or broad 
possessions of the British empire, or as adventurers seeking new 
homes and fortunes in the far west, your knowledge and your 
skill will be ever taxed in every clime and amongst every race, 



22 , OUTLINES OF FEVER. 

to stay the destroying hand of this universal enemy of our kind. 
For in some one or other of its forms, this cosmopolitan disease 
meets you in both hemispheres, and on either side of the line. 
And if you wish to be worthy of your high mission, and equal 
to the responsibilities of your calling, you must be prepared, 
with all the resources of your art, to meet this deadly antagonist 
face to face, and to dispute with him each inch of ground, remem- 
bering that the contest is for that in which no earthly power nor 
the fullest riches of the earth can avail aught, if it be not given 
to your art under God to achieve the victory over death. 

Perhaps in no position in life are the duties of a public servant 
of so high a character, of such immediate importance, and of such 
direct utility, as those of the medical officer, in either branch of 
the public service, naval or military, when he is intrusted with 
the care of the chosen troops of his country in time of war. 

It is only for the vulgar and the uninformed that war exhibits 
its greatest terrors on the battle-field. The medical history of 
every great campaign that the world has seen, tells us that the 
most murderous inventions which military science has produced, 
from the remotest times to the present, reap but a small harvest 
of death when compared with the long black list of mortality 
which the rolls of disease furnish in such fatal abundance. And 
in this mortality, fever, as we have before said, has, in almost all 
campaigns, played the largest part. M. Scrive tells us that in the 
late Kussian war 309,268 was the grand total of men of all arms 
sent from the shores of France to the East, of whom not less than 
200,000 entered the ambulances or army hospitals ; of these only 
50,000 were entered for wounds, while 150,000 were admitted for 
diseases of one kind or another, mostly fevers and dysentery. 

A complete and thorough education in the pathology and thera- 
peutics of fever constitutes, in my mind, the first and most essen- 
tial requirement of the medical officer in the public service. 

How is this necessary requirement to be obtained ? It is only 
by careful and diligent study in the clinical wards of an hospital, 
and the close following of the various phases of the disease at the 
bedside of fever cases, combined with the systematic teaching 
and guidance afforded by a chair of practice of medicine, such as 
that I have the honor to fill, and from which this important sub- 
ject will be developed to you in all its bearings. From a convic- 
tion of the paramount importance of the study of fever, it is my 



MORTALITY FROM FEVER IN ARMIES. 23 

intention to devote a special, and by no means curtailed, part of 
my course to its full consideration. 

And, gentlemen, let me impress it upon you, that if you lose 
the present opportunities which you enjoy as students of medi- 
cine in this country, where fever is always at hand to be studied 
at will, and in the fullest manner, it may never again be your 
fortune to have the opportunity of mastering its phenomena and 
the principles of its treatment, till you are suddenly called to 
assume the awful responsibility of dealing with it, when in some 
distant foreign station it springs into existence, with a force, a 
suddenness, and a malignity, that would strike terror in the 
boldest hearts and the most experienced heads. If you are not 
entirely heart-hardened and dishonest men, the conviction of 
your ignorance will then bring upon you a sense of culpability, 
if not of actual criminality, that will go far to paralyze your 
energies, if you be so unfortunate as not to be prepared with the 
previous knowledge and experience requisite to oppose success- 
fully the hostile advances of this fell disease. 

In one respect you will be peculiarly and unfortunately cir- 
cumstanced, if you are called upon to deal with an outbreak of 
fever unfortified by a previously acquired and well-grounded 
experience of it. Your general professional knowledge will be 
of much less direct avail in this than in almost all other classes 
of diseases ; for it cannot be denied that fever has a special pa- 
thology, and demands a special system of therapeutics, and for 
each of us these are to be learned solely by a practical and per- 
sonal experience of the disease, and by that alone. It is far from 
my intention to underrate the importance of the surgical part of 
your duties. But I believe that while with a competent know- 
ledge of anatomy and the ordinary principles of surgery, the 
results of even one campaign will make an efficient operator of 
the diligent and observant staff and regimental assistant surgeon, 
and prepare him for almost any emergency of the battle-field, 
nothing can supplement the want of an early and systematic 
training in the pathology and therapeutics of fever. I have 
myself guided the eager and nervous, though resolute hand, of a 
junior assistant-surgeon in his first operation in the field, and I 
have seen that same person, but a few months later, wield the 
knife with all the skill, the dexterity, and the firmness of a prac- 
tised operator. On the other hand, I have known men to be bad 



24 OUTLINES OF FEVER. 

practitioners in fever who were not deficient in ability or power 
of observation, who had passed through many campaigns, and 
who had had repeated opportunities of witnessing fever epidemics 
on a large scale, but who, from deficiency in original training and 
in the principles of the pathology and treatment of fever, con- 
tinued, and I firmly believe were ever destined to continue, 
unsafe practitioners in this great class of diseases. Indeed, I 
believe that if the groundwork of this most essential study be not 
properly laid, before you pass into the turmoil and agitation of 
active professional life, no matter what your abilities, no matter 
what your subsequent acquirements, you will never deserve that 
amount of confidence which could be safely reposed in the diligent 
student of three years' standing, who had zealously pursued the 
study of fever as taught in this city. 

I am confident that were the importance of these maxims fully 
known to, or duly appreciated by those who hold the direction 
of the public medical service in these kingdoms, steps would be 
taken to insure, as a necessary qualification for entrance into this 
branch of the service, the certified attendance of every candidate 
on a full and complete course of instruction in the pathology and 
therapeutics of fever. I feel every confidence that some such 
course will be adopted sooner or later, and that the lives of so 
many gallant fellows shall not be trusted to the chance know- 
ledge and haphazard acquirements of those who are charged with 
watching over their health. 

Here let me observe, that I in no manner wish to cast aught of 
slight or imputation upon the able medical officers of the British 
army. Amongst them will be found numerous able observers, 
and skilful practitioners and profound pathologists. Amongst 
them I number a host of fellow-students and personal friends of 
riper years, for whose knowledge and acquirements I have the 
highest esteem. But what I do hold up to public animadversion 
is, that while fever constitutes, admittedly, the most formidable of 
the scourges, or the retributive visitations, if you will, to which 
armies as well as other masses of men are liable, it should be 
possible for any person, no matter what his other acquirements, 
to be placed in charge over bodies of troops, who shall not have 
given satisfactory evidence before his nomination to such a trust, 
that he has had special opportunities for studying fever, and that 
he possesses the requisite skill and knowledge to combat this 



GENERAL PATHOLOGY OF FEVER. 25 

disease when it breaks out amongst those intrusted to his care. 
Under the present system it is impossible, it may be, and I believe 
it often is the case } that a person will be called on to treat fever 
on a large scale, who has never once set foot within the wards of 
an hospital in which fever patients are received. And this may, 
and for aught any one could show to the contrary, does occur, not 
only in garrison at home, but still worse, on distant foreign 
stations, where the advantages of professional assistance and con- 
sultation are not attainable. In this respect, and it cannot be too 
widely known, a great defect still exists in the medical educa- 
tional arrangements of the public service. 

We shall now proceed to inquire what fever is. The disease 
has been variously defined, but with no better success than is 
found to attend other attempts at systematic definition in medi- 
cine, as well as in many other branches of science. I can find no 
better definition than that furnished by Cullen, and slightly 
modified by Dr. Christison. It is, as you will see, rather a brief 
enumeration of the chief phenomena which attend the outset of a 
fever case, than a definition in any strict sense of the word. It 
is to the following effect: "After a preliminary stage of languor, 
weakness, and defective appetite, acceleration of the pulse, in- 
creased heat, great debility of the limbs, and disturbance of most 
of the functions, without primary local disease." 

You have here a very good outline of the more ordinary charac- 
teristics of fever on its first invasion of the system, but you have 
withal learned but little that is of an absolutely positive nature ; 
for, as we shall subsequently more fully see, there is but one of 
the phenomena here indicated which can be regarded as essential 
and constant. 

If you ask me to name for you a character of fever which will 
stand the test of being invariable, constant, and so far essential to 
the pyrexial state, the most advanced researches of the most 
modern school of pathological inquirers can add nothing to the 
doctrine propounded by Galen, so long since as the second cen- 
tury of our era. This great observer asserted that the essence of 
fever consisted in a ccclor prceter naturam, or an increase of the 
animal temperature of the system to a degree greater than that 
of the physiological standard. The metaphorical significance of 
the terms applied to the disease from a very early period in the 
Greek, Latin, or other languages (febris, from fervere ) to glow ; 



26 OUTLINES OF FEYEE. 

pyrexia, from kvpiaato, I am hot), implies the almost universal 
recognition of the condition of increased temperature in fever. 
ISTow the researches of modern chemistry seem to show that these 
names are in reality less metaphorical than they would at first 
sight appear to be. While, furthermore, it is proved that the 
animal temperature, whether in the physiological state of health, 
or in the pathological state of disease, is maintained by a true 
process of combustion, in no essential respect differing from that 
which takes place in any ordinary fire, or other agency consuming 
oxygen and generating artificial heat. 

It would form the subject of a digression full of interest, and 
not devoid of practical import, if I were to place before you a 
historical view of the various doctrines which have in succession 
held sway for a time in the world of medicine with regard to 
fever. I might glance at the specious doctrines of the Humo- 
ralists, the singular modifications which the humoral pathology 
underwent at the hands of the alchemists, and the half-mystic, 
half philosophic dogmas of Stahl. These latter hold, as it were, 
a middle place between the vague speculative medicine of the 
olden times, and the more exact observations of the inquirers of 
the seventeenth and eighteenth centuries, which so largely con- 
tributed to lay a solid basis for the more truly scientific and ela- 
borate researches of recent times. I could likewise dwell, with 
no small advantage to you, from the example which they afford, 
on the admirable method, the profound research, and the scientific 
acumen evinced in the labors of Bonetus, Baglivi, and Boerhaave, 
or in those of Sydenham, Morgagni, or Valsalva. I would also 
gladly avail myself, did time and space permit, of this opportu- 
nity for dwelling upon those labors of the illustrious Cullen, 
which laid the foundation of the subsequent fame of the Edin- 
burgh School of Medicine. 

But, as I am not without hope, that ere long the important 
subject of the history of our art, so entirely neglected amongst 
us in this country hitherto, will be illustrated in special courses 
of lectures, I leave for that more fitting occasion, and for an abler 
hand, I trust, this vast range of subjects, to which it would be 
impossible to do justice in this place, and which would only em- 
barrass us if we attempted here any examination of them, how- 
ever imperfect and superficial. Some very remarkable doctrines 
there are which belong to a school and a period but little anterior 



GENERAL PATHOLOGY OF FEVER. 27 

to our own, and which, till but recently, exercised a very extended 
influence on the views entertained throughout Europe with respect 
to the pathology of fever. I refer to the theory which emanated 
from the great French Anatomico-Pathological School, and which 
was supported by a body of investigators, who, for the ability, 
the profound research, and the enduring character of their inqui- 
ries, have seldom, if ever, been equalled in the history of our 
science. According to this theory, fever was regarded as the 
constitutional result, and its symptoms as the general expression 
throughout the system of the effects of a localized process of 
disease, having for its constant seat a part of the intestinal canal. 

This view was based by its supporters upon a series of inves- 
tigations, almost unparalleled for their extent, and for the com- 
pleteness with which the pathological anatomy of the various 
lesions of fever were investigated. And thus, while the theory 
itself is fast passing into the domains of medical history, such 
was the profound ability and the masterly spirit of research which 
characterized this school of inquirers, that the facts which they 
accumulated will ever remain, not alone as a monument of their 
labors, but as a permanent and valuable acquisition to science. 
On a future occasion we shall have to inquire more particularly 
into, and indeed borrow largely from, the labors of the illustrious 
Louis, and some of his colleagues, for the illustration of the 
pathology of one special form of fever, the typhoid. 

The eminent investigators of this period, amongst whom Louis 
stands pre-eminent, constituted a school of observation and theory 
combined. It was succeeded by one, which centering chiefly in 
the labors of one man, Eokitansky, of Vienna, was confined 
almost exclusively to the accurate observation and record of facts 
in pathological anatomy. It is only in an advanced period of 
your studies, that you will be in a position to recognize the value 
of the vast additions which, have been thus made to medicine by 
this great observer, almost single-handed. It may be said that 
he has given to our knowledge of disease an approach to cer- 
tainty, that till his time could scarcely have been hoped for by 
even the most sanguine inquirers. 

Before I pass from this very cursory notice of so important a 
period, I may express a hope that at some time not very remote, 
the labors of Schoenlein will be made known to you as they 
deserve. Many others there are likewise, whose names have not 



28 OUTLINES OF FEVER. 

received their due meed of acknowledgment and praise in this 
country; and whose lives and labors, influential as they have 
been in the advancement of our art, and its collateral branches 
of science, fully deserved a warmer recognition at our hands. 

In any notice of the general pathology o*f fever such as this, it 
will not be possible to pass over the investigations of a contem- 
porary school, that of Yirchow, of Berlin, and his colleagues, who 
represent the most advanced inquirers of modern medicine. In- 
deed, while we have up to the present moment but passingly 
glanced at some of the various theories which have been promul- 
gated in respect to fever, I think it will be worth our while to 
enter with somewhat of closer detail into the views of Professor 
Yirchow. For, though I am far from saying that they are to be 
considered as giving us a whole and complete solution of the 
pathological problem — what is fever? they may, I think, be safely 
accepted as embodying a large amount of what is most essential 
for the ultimate determination of this question. For my own 
part, I am fully persuaded that in following them up, we shall be 
on the right track. But be this as it may, they now occupy so 
prominent a place in scientific medicine, that I should not be 
doing justice to you or to my subject, if I did not place before 
you a brief but clear expose of them. 

Fever and inflammation, in some respects the analogues of each 
other, constitute the most remarkable of all the pathological pro- 
cesses which we are acquainted with. Though they undoubtedly 
present many opposite characters, there is, and indeed probably 
ever will be, a kind of debatable ground, in which it is extremely 
difficult, if not impossible, to assign strict limits to each. It 
would even seem that these processes may be alternate or inter- 
current; or, on the other hand, their characters and phenomena 
may be so blended, that we can only adopt the expedient of a 
mixed term to define the resultant condition. This difficulty, if 
not impossibility, of drawing a marked line of demarcation be- 
tween these great morbid processes, is practically exemplified in 
the retention in medical language of the still common and habit- 
ual expression — inflammatory fevers; in the use of which we 
recognize and acknowledge the difficulty of assigning to each of 
these great morbid states its distinct part. But, while the two 
states often unquestionably present so much of analogy, and while 
we admit that they may often coexist simultaneously and con- 



INCREASED TEMPERATURE IN FEVER. 29 

currently; you must impress it upon your minds as one of the 
cardinal points of your compass, and one of the prime canons of 
your art as practical physicians, that fever is not inflammation. 
At a further stage of our inquiry, we shall endeavor to draw 
such lines of demarcation for your guidance in this respect, as 
may be practicable in the present state of our knowledge. 

We now proceed to address ourselves more particularly to the 
question, what fever is. Of the various phenomena presented by 
fevers, that of an elevation of the temperature of the body, in 
whole or in part, is the most constant and remarkable, and has 
likewise attracted most inquiry. With Galen, as we have before 
stated, the calor prceter naturam constituted the essential pheno- 
menon; many subsequent observers have, however, refused to 
recognize it as either constant or essential. And this is not to be 
wondered at, for a very striking and obvious diminution of tem- 
perature; in several parts of the body, not only attends the outset 
of fevers, when the patient's own sensations, and the impression 
upon our senses fully concur, as to the actual coldness of various 
parts, but is often present at a late period of the disease. We 
now refer to the phenomena of intercurrent rigors, which are 
often known to occur pending the course of febrile diseases, and 
sometimes even at their very height ; algid states exemplify the 
same. 

While the determination of this question rested on the fallible 
evidence of sensation, and such imperfect tests as that of the ap- 
plication of the hand, it was obviously impossible that it could 
receive any definite solution. There was clearly but one method 
by which positive results could be obtained, such as should be 
beyond the reach, of cavil or question. Such means were fur- 
nished by the thermometer alone ; and it is only to be wondered 
at, that this test was not earlier applied. An observer of the 
German school was the first to put in practice this definite mode 
of investigation. De Haen was, I believe, the first to employ the 
thermometer to ascertain the temperature of fever. His obser- 
vations went to show the entire correctness of Galen's lemma, 
with regard to the calor prceter naturam. For De Haen found that, 
even in the rigors of fever, there was in internal parts a manifest 
increase of temperature, in some cases to the extent of 2°, 8°, and 
even 4° ; he further showed that the slightest febrile conditions 
are attended with an increase of heat, which is likewise in some 



30 OUTLINES OF FEVER. 

instances the only observable phenomenon whatever. These 
experiments have been since repeated and abundantly confirmed 
by many inquirers. The fever temperature has been determined 
in the mouth and the anus, the axilla, the folds of the groin, and 
other parts. We have now the accumulated authority of such 
men as Gierse, Eoger, Traube, Zimmerman, and Barensprung, to 
name no others, for stating that elevation of temperature of the 
whole, or some parts of the body, of internal if not of external 
parts, is a constant and unfailing attendant on the febrile condi- 
tion. So that Yirchow seems to be fully justified in the state- 
ment, that it is no longer doubtful, that in the color prceter natu- 
rarrij as stated by Galen, is the substance of fevers. What then, 
you will ask, is to be said respecting the chilliness, and even 
positive cold complained of by the patient on the invasion of 
febrile disease, and appreciable not only by the sensations of the 
patient, but also by the sense of touch of the physician ? It is 
found that these sensations of cold, which accompany the rigors 
of the incipient febrile condition, are in reality but peripheral 
phenomena ; for to use again the words of Virchow, Wahrend die 
ausseren Theile frier en, brennen die inneren, " While the outer parts 
freeze, the inner burn." These are all-important, but simple ob- 
servations, which you can readily verify for yourselves. Increase 
of temperature, then, to the extent it may be of 4° above the 
physiological standard, is to be regarded as a constant, and, so far 
at least, an essential condition of fever. And thus, while the na- 
tural blood heat in health may be assumed to be about 98°, when 
the condition of fever is established, the thermometer placed in 
the mouth, the anus, the axilla, or other suitable part, will be 
found to indicate an increase of the systemic temperature to 100°, 
102°, 104°, or it may be even a little more. 

Wow can we point to any one other condition of which it may 
be said that it is constant in fever ? I believe that we must answer 
this question in the negative ; for what we know of the pheno- 
mena of nervous disturbance, however their importance may be 
ultimately established, is yet too indefinite to be relied upon, and 
therefore increase of temperature remains as the one sole constant 
element of the febrile state, of the existence of which we have 
well-established and reliable scientific evidence. Yarious other 
phenomena indeed are, doubtless, commonly attendant upon the 
fever condition ; but it is undeniable that, with the exception of 



INCREASED TEMPERATURE IN FEVER. 31 

that here specified, any or all of them may be absent in particular 
cases. 

If we inquire what is the seat of this increased temperature, 
we shall find that wherever it may originate, and however it may 
be induced, the whole blood-mass must sooner or later participate 
in it. What its precise point of departure may be, we have no 
means of determining. It would certainly seem to be general 
rather than local. But however this be, it is obvious that the 
blood in some parts at first, and in all finally, must share in the 
general increase of temperature. It is the only all-pervading 
element: and for this reason, i.e. that it is, so to speak, an ubi- 
quitous fluid of the animal system, the blood, even though the 
change of temperature be not first and originally induced in its 
own mass, comes necessarily sooner or later to participate in it. 
In the fully developed condition of the febrile state, we may fairly 
assume that all parts and tissues of the system partake, more or 
less, of the increase of temperature, indirectly, and by commu- 
nication of heat, if not directly and by actually contributing to 
its production. We shall presently see how far it is probable 
that local and general tissue changes, or histo-chemical metamor- 
phoses of the constituent elements of the body conduce to this 
end. We shall not stop here to examine the various theories 
which from age to age have been put forward to explain the phe- 
nomena of increased temperature in fever. Certain physical 
conditions, such as increased velocity and friction of the blood- 
particles, cannot, perhaps, be altogether excluded from consider- 
ation. But in the present state of science, it must be admitted 
that the chief source of increased temperature in the febrile state 
is to be sought in an increased activity of the causes which ope- 
rate in the production of the physiological or healthy temperature. 
It is now placed beyond question, that the source of the normal 
animal temperature is to be found in the chemical development 
of heat attendant on nutrient changes perpetually going on in 
the tissues. There is no reason for seeking other sources for the 
fever heat than those which are known to furnish the natural 
heat ; they are, in the very first place, enough and sufficient, and 
beyond this it is unnecessary to go. Yirchow assumes them to 
be augmented in fever, or in other words, he assumes that the 
nutrient metamorphosis of the tissues is increased, and, as a 
natural and necessary consequence, this gives rise to increase of 



32 OUTLINES OF FETER. 

temperature. There is an increased consumption of organic ma- 
terial throughout the system ; but this is not the only departure 
from the normal action in fever, for it is not alone the materials 
supplied by nutrition that are subjected to increased metamor- 
phosis, i. e. increased combustion, which implies increased tempe- 
rature ; but the actual constituent elements of the body themselves 
undergo metamorphic changes, and are removed, and this in some 
instances to a very remarkable extent. Not only the animal 
fluids, such as blood, parenchymatous fluids, the animal oils and 
fats, but even the solids, as muscle, gland-tissue, and bone itself, 
undergo manifest diminution in volume and density in the course 
of febrile diseases, often to an excessive degree. 

Increased respiratory action has likewise been assigned as a 
cause of increased consumption of organic material, and of the 
increase of temperature, the exhaled carbonic acid thrown off 
from the lungs being taken as the standard of measurement in 
estimating the increased activity of the respiratory combustion 
powers ; and some exact observations which have been made do 
appear to show that, as far as this function is concerned, there is 
an actual increase in the process of oxidation in fever. This, 
however, is undoubtedly but an imperfect mode of estimating the 
amount of oxidation, for, as recent researches show, many organic 
substances become oxidized without the production of carbonic 
acid ; on the other hand, Moleschott has remarked that the origin 
of heat in the body is not to be attributed solely to the combina- 
tions of oxygen with organic materials, but that in the separation 
of bodies which become only in part oxidized is to be found a 
rich source for the production of animal heat. This statement is 
meant to apply to the physiological condition, but it is obvious 
that it is equally applicable to the pathological. 

However induced, increased rate and force of the circulation 
are commonly observable at an early period of fever ; increased 
circulation almost necessarily implies increased nutritive changes 
in the tissues generally, the consequences of which have been 
seen to be increase of temperature. We know likewise from the 
experiments of Becquerel and Breschet, and those of Helmholtz, 
that even artificially induced muscular movement is attended by 
increase of temperature, while it is proved from other sources of 
observation that muscular movement is attended by comsump- 
tion of muscular tissue. Other observations are not wanted to 



INCREASED TISSUE— METAMORPHOSIS. 33 

show how increase of the natural processes of nutrient metamor- 
phosis is attended with increase of temperature. We may, there- 
fore, I think, safely assume that increase of temperature in fever 
is the result of increased tissue change, which is itself imme- 
diately connected with, if not entirely dependent on, increased 
circulation, whether local or general. But in a subsequent 
Chapter we shall have occasion to prove that this assumption is 
not gratuitous, for it rests on the basis of observed facts. 

If, then, with Yirchow, we regard increased heat as the pathog- 
nomonic symptom and the essential condition of fever, and con- 
sider it to be dependent on increased metamorphosis and increased 
consumption of the constituents of the body, we have yet to seek 
the cause of this increased action in the system. This cause, the 
causa proxima, of fever, Yirchow regards as internal, and con- 
nected with the body itself, in contradistinction to the external 
cause acting on the body from without. Yarious changes in the 
constitution of the blood, productive of a matenes acris, fever- 
stuff, the pyretogen of Eisenmann, have been assumed as the 
causes of fever; but while we may hold that in many cases some 
such change is actually produced, we are not yet in a position 
either to determine its precise nature, or to understand how it is 
itself brought about. 

Some facts determined by recent investigation and experiment 
would appear to show that the first steps in the establishment of 
febrile conditions are not to be sought in the blood itself, or any 
part of the circulating apparatus; and to indicate certain de- 
ranged conditions of the nervous system, as more likely to fur- 
nish us with an explanation at once rational and probable on this 
point. 



34 GENEKAL PATHOLOGY OF FEVER. 



CHAPTER II. 

GENERAL PATHOLOGY OF FEVER. 

You must permit me to recall to your minds, in a brief reca- 
pitulation, the most essential of the facts which we considered in 
our first Chapter in connection with fever. 

After a very cursory glance at some few of the more important 
of the various doctrines which have been held from time to time 
regarding fever, we were engaged in the more immediate and de- 
tailed consideration of those remarkable views recently propounded 
by the school of Yirchow. 

"We saw that in the opinion of these eminent authorities, fever 
was essentially characterized by the condition of increased tem- 
perature, which was to be regarded as the result of an increased 
consumption of organic material throughout the system. "We 
saw that, even in the stages of rigors, the increase of temperature 
was found in some instances to reach 2°, 3°, or more degrees, 
above the physiological standard ; and that thus, while the nor- 
mal blood heat was about 98°, the temperature of fever might 
be regarded as from 100° to 102°, or 104°, or even still more in 
in some cases. 

Having shown how fever heat, increased rate and force of the 
circulation, and increased consumption of organic material, thus 
stood in close connection, we were next about to inquire how far 
the state of science at present warranted us in assuming that any 
special point of departure could be assigned for the various phe- 
nomena comprised under the head of fever. 

It was maintained by Cullen, in the last century, that the first 
link in the chain of fever actions, was a depressed state of the 
brain and nervous system. He considered that the spasm of the 
capillaries, the favorite theory of Hoffmann, resulted from this 
depression of the brain and nervous centres, and that the reaction 



SOURCES OF FEVER HEAT. 35 

of the circulation was an effort to overcome this state of spasm of 
the extreme vessels. 

I believe there can be now but little doubt that the former 
part of this proposition of Cullen has anticipated to some extent 
what we must dow admit to be an effective cause in the produc- 
tion of the earlier febrile conditions. We cannot appeal to the 
blood itself, or to any one part of the circulating apparatus, more 
than to another, for an explanation of the phenomena which are 
exhibited in fever. Increase of heat is doubtless caused by increase 
of metamorphosis of the tissues, and this in its turn we know to 
be dependent on increased circulation ; but we have still to in- 
quire what it is that causes this increase of circulation, either as 
to rate, force, tension, or other of its physical conditions. 

Knowing, as we do, from the results of various independent 
observations and experiments, that the circulation is directly 
under the control of the nervous system, we shall add one more 
link to the chain of evidences we possess respecting fever, if we 
are enabled to show that increased temperature, as resulting from 
increased circulation in fever, is in any directly assignable way 
under the influence of nervous power. 

Without very ample digression, it would not be possible to go 
at length into the accumulated evidence which can be brought to 
bear, from experiment and observation, upon the relations exist- 
ing between certain states of the nervous system, as to either 
excitation or depression of its functions, and certain phenomena 
of the circulation and of animal temperature, which stand in 
direct relation to each other. We must content ourselves with 
briefly citing what seems best established in this department of 
physiological physics, and most pertinent to the matter in hand. 
It seems pretty well determined that certain parts of the nerv- 
ous system preside over the general and local circulations, and 
through the circulating apparatus over the general and local pro- 
cesses of nutrition, and of nutrient metamorphosis of the tissues. 
It is this latter change we know which immediately influences 
the development of animal temperature ; and thus animal heat, 
through the medium of the tissue metamorphosis, by which it 
is directly generated, comes to be, in one remove only, under the 
control of the nervous system. The nerves, in fact, it may be 
stated, from their influence over the circulating apparatus, con- 



36 GENERAL PATHOLOGY OF FEVER. 

stitute the natural regulators of the development of animal tem- 
perature. 

As stated on a former occasion, when we were engaged in a 
more detailed consideration of this subject {British and Foreign 
Review, 1855), there is no reason for seeking other sources for 
the fever heat than those which furnish the natural heat : only 
it may be considered that in fever the usual processes are in 
excess, and this excess may be traced to either of two sources. 
We may suppose that certain nerves preside over the develop- 
ment of heat, or that its production is moderated by certain 
nerves ; in the former case, the febrile heat is to be attributed to 
an increased, in the latter to a diminished, innervation. The ex- 
periments of Becquerel and Breschet, and those of Helmholtz 
show, as already stated, that nervous excitation, when it induces 
muscular contraction, is attended by increase of temperature. 
In opposition to this, Bernard has proved that section of the 
sympathetic nerve in the neck is followed by rapid increase of 
temperature in the corresponding half of the head. Brown- 
Sequard's experiments are to the same effect. E. H. Weber has 
shown that irritation of the vagi nerves causes an arrest of the 
heart's action ; while it is long known that after section of these 
nerves, a remarkable acceleration of the pulse takes place. 
Ludwig and Hoffa have ascertained that, by moderate irritation 
of the vagi, the lateral pressure of the blood in the arteries is 
lessened ; while Volkman and Fowelin have established that it 
is increased after section of these nerves. A very interesting 
therapeutic experiment of Traube bears immediately upon this 
subject, and confirms the results of Weber above stated. He 
has found that digitalis acts as an irritating stimulant upon the 
regulator nerves of the heart, and that a diminished temperature 
is produced by its employment, which he attributes to the dimin- 
ished velocity of the blood-stream. The causes which regulate 
the velocity, tension, and other physical conditions of the blood- 
stream, and the vessels which convey it, seem unquestionably to 
reside in the nervous system, which exercises a sort of regulator 
or moderator function over the circulation, and through the cir- 
culation over the animal temperature. 

Now, taking into account the various phenomena which attend 
the onset of a fever, characterized as it is by weakness, prostra- 
tion, and loss of energy, especially in the muscles and sensitive 



SOURCES OF FEVER HEAT. 37 

apparatus (and all, as you must bear in mind, so rapidly induced, 
within a few hours in many cases), we may conclude with Vir- 
chow, that the elevation of temperature, which is found to be 
amongst the earliest as well as most constant of the symptoms, is 
a paralytic phenomenon. Though not identical with the ordinary 
paralytic state, it is in all essential respects analogous to it, and 
can only be produced by a loss of power in the nerves which 
constitute the natural regulators, or it may be moderators, of the 
development of animal heat. 

"With regard to this moderator function, but little of a positive 
kind is yet determined, and it seems to be indifferently assignable 
to various parts of the nervous system. 

The question of the tone of the vessels, and its alterations in 
fever, has been often the subject of consideration with physiolo- 
gical pathologists, and a large part has been assigned to the 
so-called vasi-motor nerves in the production of such changes. 
In regard to the phenomena under consideration, the cerebro- 
spinal, and the sympathetic nerves, and with these latter I think 
we may say the vagi, appear to present somewhat different pro- 
perties; thus, in paralysis of the former, i.e. the cerebro-spinal 
nerves, there is always a greater or less diminution of tempera- 
ture in the parts which they supply; while, as regards the latter 
group, i. e. the sympathetic and the vagi, they retain their power 
even in cases of complete paralysis of the cerebro-spinal system, 
and this power may be increased when the branches connecting 
them with the spinal marrow are paralyzed, and this may like- 
wise be accompanied with an increase of temperature. 

There seems to be great reason for selecting the vagus as one 
of the most important agents concerned in the production of the 
chief febrile phenomena. Besides the elevation of temperature, 
the alterations in the general circulation, and the movements of 
the heart, the lesions of the digestive functions, anorexia, vomit- 
ing, &c. &c, as well remarked by Yirchow, fall within the domain 
of the physiological influence of the vagus. The lesions of the 
heart, the lungs, and the stomach, fall thus into one category; 
and, as suggested by Traube, these, as well as a large number of 
the other symptoms of fever, may be referred to a weakened, i. e. 
a more or less paralytic condition of the vagus. 

I may here mention, in connection with the experiments just 
detailed, and upon which these views are based, that observations 



38 



GENERAL PATHOLOGY OF FEVER. 



made by Lichtenfels and Frolich appear to show that in the 
normal condition the frequency of the pulse and the temperature 
are independent of each other. What Lichtenfels and Frolich 
have shown respecting the want of correspondence between the 
pulse-rate and temperature, in the physiological state, my obser- 
vations establish for the fever condition. The following combina- 
tions of pulse-rate and temperature were recorded by me in 
certain cases of yellow fever in the Lisbon epidemic of 1857 ; 
they supply a desideratum. 



Fair. 



1. In case 


with, pulse 


at 113 per minute, the thermometer in axilla gave 








a temperature of 


102O 


2. " 


u 


100 * 




100O 


3. 


11 


112 * 




104O 


4. 


a 


104 « 




103O 


5. " 


it 


92 




101O 


6. 


a 


100 * 




I03JO 


7. 


a 


104 ' 




103O 


8. 


u 


100 




104|o 


9. 


a 


84 




990 


LO. 


a 


70 




loop 



From this table it will be seen that the highest pulse-rate and 
the highest temperature did not correspond. On the contrary, 
the highest pulse at 113 had only a moderate elevation of the 
thermometer, 102°, while the pulse at 100 gave the highest tem- 
perature, 6|° above the physiological standard, and a temperature 
of 100 J° (with noticeable calor mordax) attended a pulse at the 
normal rate. There was, therefore, no uniformity of relation 
between the two sets of phenomena ; and this we believe to be 
not at all uncommon. 

These results may, at first sight, appear contradictory to the 
views we have accepted; but on closer inquiry you will find that 
it is not so. The frequency of the pulse under many conditions, 
and more especially in fever, is a most inadequate and unreliable 
test of the most essential states of the circulation. Even the 
heart's contractions will be often found to be an imperfect crite- 
rion of the state of the circulation ; great rapidity of its beats may 
often be ascertained to be attended by an incompleteness and 
weakness of its ventricular contractions. Indeed, so imperfect 
are these contractions sometimes found to be, that the mass of 
the blood, instead of moving with increased velocity, is retarded, 
and flows more slowly than usual. The same is to be said of 



STATE OF THE NERVES IN FEVER. 39 

arterial contractions which, when most frequent, are often, as we 
know, attended by a most imperfect circulation of the blood-mass. 
As temperature is entirely dependent, not so much on the rapi- 
dity as the efficiency of the circulation, we should be prepared 
for, and indeed expect, that mere frequency of pulse is no mea- 
sure of temperature, or vice versd. You must therefore bear care- 
fully in mind, that the state of the circulation, whether physio- 
logical or pathological, is to' be estimated, not so much by the 
apparent energy and the number of the heart's contractions, or 
those of the arteries, which taken singly are very fallacious guides, 
as by the general tension of the whole vascular system. In prac- 
tice you must carefully examine and weigh every physical and 
vital condition of both heart and arteries. The force of the 
heart's shock, as well as its extent, and the completeness of the 
ventricular systole, must be carefully determined by the hand 
and by the stethoscope; at the same time your observation is to 
be corrected by careful examination of the arterial pulse at va- 
rious points, at least in the carotids, the radials, the abdominal 
aorta, and the femoral arteries. These examinations may seem 
tedious, but they can be both rapidly and carefully made by the 
quick skilful touch of the practised physician. 

Fever, then, in the opinion of Yirchow, essentially consists in 
an increase of temperature, which is caused by an increased con- 
sumption of organic material in the system, and appears to have 
its origin in certain changes in the nervous system. These 
changes may be considered to affect primarily the regulator or 
moderator-functions of the nerves ; and to be of a paralytic nature. 
It is probable that the vagi nerves, and we would add the sym- 
pathetic, are primarily if not chiefly engaged in the production 
of the febrile phenomena. 

If we seek for the determination of any centre for the regulator- 
functions of the nerves, and especially of the vagi, it will, in the 
opinion of Yirchow, be most probably found to reside in the me- 
dulla oblongata, near the roots of the vagi. 

Yirchow believes that every given disease and every lesion 
may pass into a fever, if it invades the regulating centres of the 
consumption of nutrient material. As these centres are to be 
sought only in the nervous system, an abnormal state of tension 
or irritation of them must be admitted, which is called into play 
by the causes exciting the fever, and which finds no solution in 



40 GENERAL PATHOLOGY OF FEVER. 

the natural processes. As the power of the moderating centres 
is arrested by the abnormal tension or irritation, the consumption 
of material advances throughout the tissues, and in proportion 
the heat of the body increases, and the particular point of the 
commencement of fever is reached. At first we see only the 
weakening of the corporeal and mental powers which follows di- 
rectly on the condition of tension or irritation being induced, and 
this in some instances with such a force and suddenness of the 
prostration of the vital powers as to suggest the idea of a true 
paralytic invasion of the nervous system. 

What has been hitherto but surmise upon this subject is now, 
as we have seen, reduced to the domain of probable fact. And it 
is at least possible that the fever-poison first invades the animal 
system through the channel of the nerves. In your practical ex- 
perience of the disease you will not infrequently meet with per- 
sons, and their evidence on the subject is very credible, who will 
tell you that they distinctly felt the first impression of the fever- 
poison, or, as we term it, the fever-shock. I have myself a distinct 
remembrance of the circumstance in my own case, when I " took 
the fever," some years since, from a particular case of the worst 
form of maculated typhus in the Meath Hospital. When scientific 
research and common experience coincide, as in this instance, you 
may feel pretty well assured that scientific inquiry is fairly upon 
the path of truth. For myself, I believe that in the line of inves- 
tigation now being pursued we are on the right road to a whole 
and satisfactory theory of fever ; we are, however, some way from 
this desirable end as yet. 

Such is a brief outline of the views which now appear most 
tenable with regard to the nature of fever ; much is yet left unde- 
fined, and there is also much which will present itself to the mind 
of every practical physician as difficult to be brought within these 
limits. To those especially who have pursued close and accurate 
clinical studies of typhus fever, many points in its pathology will 
doubtless appear to be, as yet, at all events, incapable of solution 
by the theories of Virchow and his colleagues of the Berlin 
school. 

We shall here pause for a brief space in our more immediate 
inquiries with respect to fever, in order to bring forcibly into 
contrast for you some of the more recent results of research with 
respect to inflammation. 



NATURE OF INFLAMMATION. 41 

Inflammation constitutes in some respects the analogue, in 
others the opposite of fever : next to fever it must be considered 
as the most remarkable of all pathological processes. Virchow 
describes it as one of the general forms of compound phenomena, 
under which most different local diseases may manifest them- 
selves. As in fever, the most remarkable phenomenon of inflam- 
mation is an elevation of temperature. In the former disease we 
found this to be general, while in the latter it is only local ; and 
this character, viz., localization, may be persistent throughout the 
whole course of a given inflammatory process. This cannot be 
the case in fever. 

We shall omit here all notice of the various doctrines held 
from time to time as to the essential characters of inflammation, 
from the symptomatic quatrain of Celsus (the tumor et rubor, cam 
cahre et dolore), to the fluxus, stasis, constriction of the capillaries, 
obstruction and stasis of the blood-stream and the error loci of the 
globules. These subjects are discussed at length for you by able 
surgical writers. Suffice it to say, that two most opposite condi- 
tions of the bloodvessels, spasmodic action and paralysis of their 
walls, have been assigned as causes for some of the most essential 
phenomena of inflammation, and each has received the support of 
distinguished investigators. It is now, however, pretty generally 
agreed upon, at all sides, that the local alterations of the circu- 
lation, in themselves neither simple nor uniform, are insufficient 
to define inflammation ; it is said that not any one of the many 
phenomena assumed by various observers to be essential, is con- 
stant, and that even opposite states of the blood and bloodvessels 
may present themselves in succession within a short period in 
the same inflamed spot. It is even asserted, as by H. Weber, 
that the state of the vascular walls, whether it be one of paralysis 
or of spasmodic action, is of but secondary importance in refer- 
ence to the stasis of the blood-stream. The theory which seems 
to invite most attention at present is that known as the attractive 
theory, which is based on certain physical relations found to 
exist between the blood, the vascular walls, and the parenchyma. 
In estimating this attractive force, several conditions come into 
play, as, for instance, the viscosity and cohesion of particles in 
the circulating fluid itself, and the molecular attraction between 
them and the walls of the vessels. Virchow accepts the attractive 
theory as capable of explaining the stasis, but not necessarily 



42 GEXEEAL PATHOLOGY OF FEYEE. 

therefore the inflammation. The phenomena of stasis of the 
blood-stream, as observed in the web of the frog's foot under the 
microscope, have been so often described, that we need not here 
dwell on such details, as, for instance, the diminished velocity, 
partial intermission and oscillation of the blood-column, gradual 
disappearance of the intercellular fluid, the lessening of the dia- 
meter of the blood-corpuscles, and their increase in number till 
they fill the entire vessel, and the whole mass stands still. As 
to the part which the surrounding tissues bear in the process, it 
is chiefly as to the exudation that we have to speak. Tirchow 
regards the exudation in no other light than as the nutritive 
fluid — blastema, or liquor sanguinis, of other writers — which has 
passed from the blood into the substance of the tissues, and which 
cannot be separated from them or isolated. It has entered into 
their cells and become a constituent element of their nuclei and 
granules, and can hardly be regarded as distinct from them. 
Exudation is not to be considered, then, as a product proper to 
inflammation, it is only a concomitant phenomenon, though often 
largely in excess of the physiological limits ; the products of in- 
flammation are, as it were, like those of a process of destructive 
distillation, and are represented by the disintegrated tissue ele- 
ments which become, so to speak, excrementitious, and must be 
thrown off. The inflammatory process is to be regarded as a 
local lesion of nutrition, and as such it depends for some of its 
most essential phenomena upon the interchange of materials be- 
tween the blood and the tissues. 

Elevation of temperature has been long known as a marked 
characteristic of the inflammatory process : it constituted, as we 
know, one of the four cardinal phenomena insisted on by Celsus. 
Experiment and observation give somewhat conflicting results as 
to the exact conditions of temperature in inflamed parts ; the 
weight of argument is. however, on the side of an absolute in- 
crease. Increase of temperature in inflamed parts was ascer- 
tained by John Hunter, and more recently by the thermo-electric 
method in the hands of Becquerel and Breschet. Tirchow 
considers it as highly probable that increased heat is produced 
in inflamed parts, but that the temperature of the foci of inflam- 
mation is to be regarded as the expression of two distinct sources 
of heat, one of which is to be sought in the blood, and the other 
in the parts themselves. The local elevation of temperature pro- 



FEVER AND INFLAMMATION CONTRASTED. 43 

duced by the increased influx of blood, always determined in 
excess towards inflamed parts, must contribute in some measure 
to the increase of the local metamorphosis of tissue. 

The intermediate state, known as irritation, deserves some 
notice here. It is one in which there is a departure from health, 
but yet inflammation is not set up. It is, as it were ; the first step 
towards inflammation, but has, while such, only a functional cha- 
racter, and one which does not involve any lesion of nutrition. 
If it implicates nutrition it has then, ipso facto, passed into 
inflammation ; while it remains functional the several parts, 
nerves, vessels, and tissues may at any moment recover them- 
selves, and regain their normal state, without the production of 
physical or increased chemical, changes, other in kind or degree 
than those which are continually going on in the physiological 
process. 

There appears then, if we adopt the views of Yirchow, to be 
no specific ontological, or essential character which we can assign 
to inflammation as constant or pathognomonic. And this is true 
of the various conditions of the circulation, the state of the blood 
and the blood-corpuscles, as well as of the phenomena of tumor, 
redness, heat, and pain. The inflammatory process has no specific 
difference from other lesions of nutrition, but it is characterized 
chiefly by its extent, the rapidity of its course, and more espe- 
cially by the lesions it produces in the structures it invades. Its 
destructive tendency is that by which it is most remarkably dis- 
tinguished from any simpler lesions of nutrition, and in this will 
be found the most marked difference between the physiological 
and the pathological process. 

Such is a brief outline of the most essential phenomena of 
inflammation. Let us now see how far we can trace some analo- 
gies, and in what draw marked contrasts between Fever and 
Inflammation. Fever is of general or systemic origin ; inflam- 
mation is essentially of local origin. Fever and inflammation are 
both characterized by increase of the animal temperature, in- 
creased metamorphosis of tissue, and increased circulation. 

In fever these conditions are produced generally and simulta- 
neously throughout the system : in inflammation they are essen- 
tially local in their origin, and if the inflammatory process remain 
purely such, they may never extend beyond the limits of the 
inflamed structures. 



44 GENEEAL PATHOLOG-Y OF FEVEE. 

In fever (purely such) the nutrient metamorphosis, though 
commonly attended with interstitial absorption, progresses in 
both tissues and organs without injury to their structure, and it 
may be without interference with their functions. If inflamma- 
tory or other processes supervene, the case is of course different, 
and structures and functions may be destroyed. 

In inflammation, on the other hand, local change is induced, 
often to the extent of complete disorganization and destruction of 
tissue, with the result of organs being spoiled. 

To make this more clear by example : Suppose a case of fever, 
purely such, without inflammatory or other complication, to be 
suddenly arrested by death ; suppose a similar occurrence in a 
case of inflammation of the lungs or of any other organ ; in the 
former case, if we examine the organs with minutest care, and all 
the aids of microscopic inquiry, we can detect no change, except 
such as may be as the result of increased metamorphosis ; inter- 
stitial fat and fluids will be absorbed, and the organ will be lighter 
and less dense ; it is needless to say what changes visible to the 
naked eye, and of gross physical character, will be observable in 
the instance of organs or tissues which are the subject of inflam- 
mation. 

Fever has its origin in conditions over which we have no con- 
trol under almost any circumstances whatever, and which are at 
best but little explicable. 

Inflammation very commonly takes its rise from the effects of 
mechanical, chemical, or other irritants upon the animal struc- 
tures ; and true and complete processes of inflammation can be 
called into play, in any organ or tissue, almost at the will of the 
experimental pathologist, by the application of various mechanical, 
chemical, or other stimulants. Lastly, and this is perhaps the 
most important point of difference, especially to the practical 
physician, as you will subsequently more fully understand, in- 
flammations are, to a very large extent, at all events, directly 
under the control of therapeutic agents ; so far, at least, that 
inflammatory processes can be often, if not arrested, checked, 
modified, or so influenced that their destructive tendencies can be 
limited. As regards the true fevers, I am, for myself, persuaded 
that any attempts at arresting them, or altering their course by 
any system of therapeutics, by the exhibition of purgatives, 
emetics, diaphoretics, or other means presumed to be capable of 



45 

causing the fever to abort, as it were, or to bring about a prema- 
ture crisis, are so much worse than useless, that they often pro- 
duce positively mischievous, if not fatal results. 

Thus, while I believe it may be said with truth that we can 
cure many inflammations by the intervention of our art, the same 
cannot be affirmed of fevers. In fevers, the highest efforts of 
our art, the most delicate care, the most refined skill, the most 
nice appreciation and adaptation of means to ends which we can 
command, must be all directed to watching, supporting, main- 
taining, and it may be stimulating the system till the fever-storm 
shall have passed over it. In fever cases your duties, as practical 
physicians, will be like those of the sailor whose ship is riding 
out the gale. With firm hand and ready eye he is prepared for 
every emergency that can arise ; but he neither puts on sail nor 
club-hauls his ship till the actual moment of danger arises. It 
must be the same with the physician in the management of a 
fever case ; he must act on the defensive, not on the offensive. 
Press your ship too much, and she founders ; meddle but never 
so little too much with the fever, and your patient dies. 



1 

46 CLASSIFICATION OF FEVERS. 



CHAPTER III. 

CLASSIFICATION OF FEVERS. 

I AM far from, regarding our knowledge of the aetiology and 
general pathology of fevers as sufficiently advanced to enable us 
to classify the various forms of these diseases which are met with 
in practice on any truly scientific basis. But I consider the fol- 
lowing arrangement to be free from grave practical objections, 
and it is at once simple, comprehensive, and readily committed 
to memory. 

We shall regard all fevers as reducible to three great types, 
viz : — 

I. Primary Fevers. 

II. Irritative Fevers. 
III. Eruptive Fevers. 

The first of these groups may be again subdivided as follows : — 

Primary fevers comprise Continued, Intermittent, and Remittent 
fevers ; and each of these classes is again made to embrace sub- 
divisions which will be more readily comprehended in their 
mutual relations by an inspection of the following scheme, exhibit- 
ing at one view a classified arrangement of the several kinds of 
fevers recognized by the best writers. 

I. PRIMARY FEVERS. 
(a.) Continued Fevers : — 

Synocha, or Inflammatory Fever. 

Synochus, or Mixed or Nervous Fever. 

Typhus, or Adynamic Fever — Spotted or Irish Fever — Putrid Fever. 

Typhoid, or Enteric Fever. 
(&.) Intermittent Fever, or Ague : — 

Quotidian. 

Tertian. 

Quartan. 



CLASSIFICATION OF FEVERS. 47 

(c.) Remittent Fever : — 

Paludal Fever, comprising Marsh Remittent, Eilious Remittent, and 
Yellow Fever. 

II. IRRITATIVE FEVERS. 

Gastric Fever. 

G astro- Intestinal Remittent. 

Hectic Fever. 

III. ERUPTIVE FEVERS. 

Variola — Smallpox. 

Rubeola — Measles. 

Scarlatina — Scarlatina. 

Miliaria, Miliary or Sweating Fever. 

GENERAL CHARACTERS OF THE THREE GREAT GROUPS OF THE PRI- 
MARY, THE IRRITATIVE, AND THE ERUPTIVE FEVERS. 

The primary fevers are essentially characterized by the de- 
velopment of a geueral pyrexial state, independent of specific 
pathological lesion, and having no necessary connection with 
localized disease in any portion of the body, or in any organ or 
tissue. All organs, and perhaps all tissues, participate in the 
febrile action when once it is established ; but it cannot be said 
to originate in any one part more than in another, saving so far 
as the considerations already adduced, show that the first link in 
the chain of morbid actions may be found to implicate the nerv- 
ous system. These considerations, it is to be observed, apply 
with equal force in all classes of fevers. 

An apparent exception to the above rule offers itself in the case 
of the typhoid or enteric fevers, which so constantly present the 
associated condition of disease of the minute glandular apparatus 
of the intestines. But even here the relation of the enteric lesion 
to the fever is certainly not that of cause and effect ; nor, again, 
is the connection proved to be one of an absolutely constant kind. 
In all the other forms of primary fevers, of what kind soever, it 
is beyond question that death may ensue as the result of the in- 
fluence of the pyrexial action on the system, and yet it shall be 
impossible for the most minute pathological research to define 
the part or organ which more than another is the seat of cog- 
nizable lesion. Indeed, as is well known, primary fever may be 
fatal without a single organ in the body presenting recognizable 
physical change of any kind. 



48 CLASSIFICATION OF FEVERS. 

The Irritative fevers, on the other hand, owe their existence to 
lesion of a well-defined kind in particular parts of the system. 
They have a true anatomical seat or origin, and are to be regarded 
as the constitutional expression of localized disease. A gastric 
or a hectic fever has, in fact, the same relation to the localized 
pathological process which causes it, as the pyrexial or febrile 
state attendant on ordinary local inflammation, whether of the 
viscera or external parts, bears to the physical disease which 
lights it up in the system. 

While, therefore, the Primary fevers are independent of all 
localized diseased processes, and are commonly to be met with 
unattended by pathological changes of any kind, the irritative 
fevers recognize no existence independent of local disease of some 
kind. They arise directly from, and are, as already stated, the 
constitutional exponent of specific disease in certain parts or 
organs. Thus, gastric fever and gastro-intestinal remittent origi- 
nate in certain states of irritation or subacute inflammation of the 
mucous surfaces of the stomach and intestines. Hectic fever, in 
a similar manner, is the exponent of tubercular disease in certain 
stages, or, under the name of pyogenic fever, of that state in which 
pus is absorbed into the system. It seems to me more than 
doubtful whether the so-called irritative fevers should continue 
to hold a place in the category of true fevers. Not only is their 
origin, as just stated, different from that of the primary fevers, 
and also from that of the eruptive fevers, but in many important 
particulars of their natural history broad lines of distinction sepa- 
rate them from the essential fevers. Their clinical history will 
be found to be not that of fever states, but of the local diseases 
with which they are associated. Unlike either the primary or 
the eruptive fevers, they are not known to be either endemic or 
epidemic ; they do not seem to affect particular localities, and we 
are without precedent that they have ever simultaneously invaded 
masses of men. 

The eruptive fevers are characterized by the absence of all 
specific lesion of the more important viscera ; while the cuta- 
neous surface is so frequently the seat of pathological processes 
in these fevers, that in the majority of instances our diagnosis 
between the individual fevers of this group depends on the 
special character of the rash or eruption presented on the skin. 
It is true that we hear of a scarlatina, a rubeola, or a variola, 



CHARACTERISTICS OF SEVERAL FEVERS. 49 

"sine eruptione," but it is only an exemplification of the old 
canon, that the exception proves the rule. The pathology of 
these fevers is further complicated by the remarkable tendency 
— well evidenced at least in two of them, measles and scarla- 
tina — to the secondary engagement of a more or less limited 
portion of the mucous surface. Scarlatina, as is well known, is 
commonly attended with a peculiar and characteristic form of 
sore throat ; while measles is usually accompanied by a watery 
exudation from the eyes and nose (coryza), and a bronchitic 
affection varying in extent and importance. Smallpox offers an 
example of liability to lesion of the serous surfaces (pleurse espe- 
cially), and occasionally of the mucous coats of the intestines 
(pustules on intestinal mucous surface), but with far less consider- 
able regularity than is observed in respect to the secondary lesions 
attending measles and scarlatina. 

Like the primary fevers, the eruptive fevers frequently occur 
as wide-spread and fatal epidemics. In one essential particular 
they are imitated by only the typhus and the typhoid amongst 
the primary fevers, viz., that an attack of any of these fevers gives 
a certain protective immunity against its recurrence in the same 
individual. 

One of the eruptive fevers offers the most singular instance we 
are acquainted with in the whole domain of medicine, of one 
diseased process being excluded by another. I allude of course 
to the protective influence of the vaccine virus derived from the 
cow, which produces such effects in the human subject as to ma- 
terially lessen the natural liability to the invasion of smallpox, 
and in the great majority of cases to greatly modify the course 
and results of the disease when it occurs in an individual pro- 
tected by vaccination. 

Lastly, all the true fevers differ from the febrile or pyrexial 
states attendant on local or general inflammations, in the periodi- 
city and more or less stereotyped character of their principal 
phenomena; in running a more or less well-defined course; in 
their faculty of producing such lasting effects on the human con- 
stitution, that at least the more important of them seldom occur 
twice in the same individual; and, lastly, in their power of epi- 
demic invasion. 
4 



50 CLASSIFICATION" OF FEVEES. 



CONTINUED FEVERS. 

General Notions. 

We have seen that the Primary fevers admit of subdivision 
into the Continued, the Intermittent, and the Eemittent. Broad 
and well-marked characteristics distinguish these forms of disease 
from each other, and no doubt can exist that they constitute 
groups of diseased action perfectly true to nature. In this part 
of our subject we find, so far, an example of strictly truthful and 
natural classification in disease. 

In the continued fevers the pyrexial state, though subject to 
exacerbations, which may be either periodic or irregular, will be 
found to be a continuous action throughout; from the first inva- 
sion of the disease to its termination. The tension (or depression) 
of the nervous system ; the rate and other conditions of excite- 
ment of the vascular system, and the activity of the general 
tissue-metamorphosis throughout the body, and consequently the 
animal temperature, are all maintained at a standard above the 
level of health. They are, so to speak, kept above par continu- 
ously ; and the human machine is, as it were, working at a high 
pressure, with an unremitting strain on its various parts. The 
whole series of actions involved may be gone through in a day 
(perhaps in less), or may be continued for two, three, four, five, 
seven, ten, twenty, or thirty days, and in some cases even still 
longer. But sooner or later a period arrives at which the febrile 
action is finally brought to a close, in some one or other of seve- 
ral ways, to be subsequently considered; and here the pathologi- 
cal processes finally terminate, not to be renewed again, except 
in the instance of the relapsing fever, and certain exceptional 
cases of pyrexial action, reinduced as the result of secondary 
processes of disease. 

INTERMITTENT FEVERS, 

General Notions. 

In the intermittent fevers the series of actions which constitute 
the fever go through their course with singular regularity within 
an excessively short space of time — a day, half a day, or less. 
They are brought to a final conclusion within this period, and it 



NATURE AND ORIGIN OF INTERMITTENT FEVER. 51 

is as if the whole train of phenomena, which in an ordinary fever 
occupies from seven to twenty-one days, was compressed into a 
few hours; and then, without the exhaustive results consequent 
on a protracted period of disease, the patient is restored to his 
normal state, or at least to one of comparatively perfect health. 
Subsequent, then, to the pyrexial action a period ensues in inter- 
mittent fever, in which the state of the patient is perhaps that of 
perfect health and strength, and in which, as it often happens, he 
is able to pursue his ordinary avocations, bodily as well as men- 
tal. This is followed on the next day, the next day but one, or 
at a still longer interval, on the fourth clay inclusive from the 
■first attack, by a renewal of the pyrexial phenomena, in the same 
order, with very much of the identical characters which they 
manifested at first, and with a singular regularity as to the hours 
of the day, the duration, and other elements of time which marked 
the primary attack. An apyrexial period again ensues as before ; 
and now, with a periodicity of most singular regularity in time 
and circumstance, the patient becomes the conscious victim on 
certain days of febrile attacks of well-defined character and dura- 
tion. This train of actions may continue for a very protracted 
period, so, in fact, in some instances, as to be extended over many 
months. A pyrexial state with characters such as those just de- 
lineated, is designated an intermittent fever. 

This class of diseases is remarkably influenced, if not in the 
vast majority of instances directly and exclusively originated, by 
conditions of climate, soil, temperature, moisture, and atmospheric 
impurities. The intermittent fevers are often of very persistent 
character, often difficult of eradication from the system, and in 
some instances they adhere through life to individuals who have 
been long exposed at some period or other to the combined cli- 
matic, meteorological, or terrene conditions capable of primarily 
inducing the disease. Amongst the secondary lesions induced 
by intermittent fever is that of an enlarged condition of the spleen. 
A singular controlling influence, which to a considerable extent 
may be strictly regarded as a curative power, is exercised over 
the fevers of this type by the active therapeutic principle con- 
tained in the bark of a large family of tropical plants, the Cin- 
chonacese. The Jesuit fathers have the credit of first introducing 
into Europe the knowledge of the therapeutic effects of the va- 



52 CLASSIFICATION OF FEVERS. 

rious species of cinchona bark. Their order has thus conferred 
a lasting benefit on humanity. 

REMITTENT FEVERS. 

General Notions, 

The Eemittent fevers are distinguished by a more or less com- 
plete relaxation of the pyrexial tension of the system, without at 
any time such a total suspension of the fever phenomena as occurs 
in the intermittent fevers. Eemittent fever is usually a disease 
of daily exacerbations and paroxysmal accessions, with subse- 
quent diminution of the pulse-rate, temperature, nervous tension, 
tissue-metamorphosis, and such other pathological phenomena as 
make up the fever, of whatever special kind it may be. There 
seems, however, to be no strictly defined periodicity in the recur- 
rence of the exacerbation and relaxation of these diseased pro- 
cesses. The fever paroxysm may remain at its full height for 
twelve ; twenty-four, thirty-six, or forty-eight hours, and Hunter 
relates a case in which no remission was observable for seventy- 
two hours. In other instances there is observable in the fever 
not so much a tendency to the occurrence of exacerbations and 
remissions, marked by the hour or the day, as a natural division 
of the fever into two or more periods or stages, of irregular du- 
ration, and between which occurs an interval in which the patient 
appears to be convalescing, though there is not in reality any 
approach to the restoration of the physiological equilibrium. 

Eemittent fevers, of almost all kinds, likewise present a well- 
defined tendency to implication of certain viscera. The stomach, 
duodenum, and liver, and, in a secondary manner, the cerebral 
organs, are constantly engaged in almost all forms of remittent. 
Violent headache, with a distressing sense of tension across the 
forehead, rachialgia, or pain in the back, gastric irritation, with 
or without bilious vomiting, and not infrequently yellow colora- 
tion of the conjunctivas, and general cutaneous surface, are phe- 
nomena of very frequent occurrence. Exudations of blood from 
the mucous surfaces occasionally give rise to the ejection of blood 
from the mouth and anus, constituting in the former instance the 
well-known and justly dreaded symptoms of " black vomit." 

In still more aggravated forms of remittent, a general hemor- 



NATURE OF REMITTENT FEVER. 53 

rhagic lesion is induced, partly dependent, no doubt, on chemical 
changes of ill-defined nature in the circulating fluid itself. 

The nosology of remittent fevers is still in a condition the most 
ill-defined and unsystematic. The geographical divisions of the 
disease are as unscientific as those which are made dependent on 
changes of season and climate. Thus we hear of summer and 
autumnal remittents, East and West Indian remittents, Walcheren 
fever, Bulam fever, hill and jungle fever, fevers of Sierra Leone, 
Fernando Po, Bight of Benin, African, Bengal, lake and marsh 
fevers, &c. &c. 

With most writers, yellow fever still occupies a position in the 
nosological scale of the most equivocal kind. As there is no 
ground for regarding it as a disease, sui generis, we shall place it 
under the head of remittent fever. 



54 SIMPLE CONTINUED FEVEES. 



CHAP TEE IV. 

SIMPLE CONTINUED FEYEKS. 

We apply this term to a form of pyrexial action of variable 
intensity and duration, unattended by specific cutaneous erup- 
tions of any kind, and presenting no constant lesion of internal 
parts. At a variable interval, after exposure to extremes of beat 
or cold, tbe direct action of the sun's rays, over-exertion and 
fatigue, excess in food or drink, peculiar states of tbe atmosphere, 
change of locality or climate, certain depressing moral influences, 
and various causes of an ill-defined character, the system of per- 
sons previously in health begins to manifest the results of the 
morbid influences impressed upon it. 

A sense of languor, debility, incapacity for bodily exercise, 
with or without tremors in the limbs, disinclination or actual in- 
capacity for mental exertion, and sometimes a confusion of ideas, 
with partial, momentary, or continuous loss of memory, or other 
mental faculty, with or without headache or drowsiness, impair- 
ment of vision, or of some other of the special senses, are the 
chief symptoms complained of. 

The patient feels an " all-overishness," says he "does not know 
what is coming over him," and the state known as malaise is 
established. This condition may remain for days, a week, or 
even more ; it may be regarded as the period of incubation of 
the disease ; loss of appetite, with more or less of gastric derange- 
ment, are often observable, but I have known a patient to eat his 
meals as usual during the whole of the period of malaise. The 
duration of this period is variable ; it may be but a few hours, it 
may even not be perceived by the patient, and the fever may, 
doubtless, set in with a more rapid and well-marked invasion. 
When the condition of malaise has lasted for some time, a more 
distinct set of symptoms is ushered in. Headache, pains in the 
back, loins, limbs, a sense of being beaten or bruised, and a feel- 



TERMINATION BY CRISIS. 55 

ing of universal soreness and excessive weariness in all the bones 
and joints, 1 are now the most prominent features of the case. 
Chilliness, rigors or shiverings, or sense of cold water pouring 
down the back, a general shrunken and shrivelled state of the 
integuments, especially in the fingers and toes, absolute coldness 
of the surface in various parts, more particularly in the extremi- 
ties, which are often livid or blue, constitute a part of the true 
fever state, which may be conveniently called the algid stage. 

The cold complained of by the patient in the algid stage is a 
positive phenomenon, sensible not only to the patient, but to the 
hand of the bystander, and demonstrable by the thermometer. 
The temperature of external parts falls to the extent of two or 
more degrees below the healthy standard (98° Fahr.); I have 
myself not noticed it below 96°, but it is recorded (Thompson) 
to have fallen so low as 92°. 

The feeling of cold is one that causes great misery and distress 
to the patient. The face is pinched, shrunken, and anxious, he 
lies cowering under the bedclothes ; loudly audible chattering of 
the teeth, and a shaking of the whole person, sufficient to cause 
the bed and all about it to vibrate strongly, are met with in ex- 
treme cases. The diminution in volume of external parts is sen- 
sibly marked by the falling off of rings; the fingers become 
shrivelled up and wrinkled like the washerwoman's fingers, and 
the skin generally assumes the rough wrinkled state called cutis 
anserina, or goose's skin. 

The duration of these phenomena, constituting the algid period, 
is very varied; they may last for a day, or even more, or be ter- 
minated within an hour ; from six to eight hours may be regarded 
as the average. Headache, temporal or general, pains in the eye- 
balls, aching in the back, loins, or extremities, nausea, with or 
without vomiting, uneasiness, distress, or pains in the epigastrium 
or other parts of the abdomen, are sometimes present during the 
algid period ; diarrhoea is an occasional but not constant symp- 
tom, constipation being just as often observable. 

Period of reaction. — To the algid stage succeeds that of reac- 
tion ; the pulse now rises in frequency, its force and volume are 
increased ; it sometimes acquires great tension and hardness, but 
not infrequently remains soft and full. Vascular excitement is 
observable throughout the system, the cardiac impulse is increased 
in strength and fulness, the carotids and temporal arteries beat 



55 SIMPLE CONTINUED FEVERS. 

with much force, and the throbbing of the vessels of the head and 
neck, and especially of the temporal arteries, is a symptom often 
most distressing to the patient. The face becomes hot and flushed, 
the eyes prominent and lustrous, and they are occasionally blood- 
shot and red. The surface of the body is hot, a sense of heat and 
suffocation oppresses the patient, and an actual elevation of tem- 
perature is recognizable by the hand, and its amount may be 
measured by the thermometer. The temperature under the 
tongue, in the axilla, or in the anus, ranges from four to six de- 
grees above the standard of health ; it has been noted at 102°, 
104°, and even so high as 107° Fahr. The skin feels pungently 
hot, giving the sensation known as color mordax, or biting heat. 
Some wandering or delirium is not infrequently present at this 
stage ; the patient becomes more hot and uncomfortable towards 
evening, and may rave during the night. Violent delirium is 
occasionally to be met with in these cases, the patient being rest- 
less, struggling to get out of bed, and with difficulty kept in the 
recumbent position. 

At this period the bowels are generally confined, and the urine 
is high-colored and scanty. 

The assemblage of symptoms now specified may be variously 
grouped in different cases, and more or less modified as to their 
order of succession and their intensity and duration. The pyrexial 
or febrile state, thus constituted, when once established in the 
system, is continuous and uninterrupted throughout, till brought 
to a termination in some of the ways to be now noticed. 

After being protracted for a period which may vary from one 
day, or even half a day, to one, two, or more weeks, the febrile 
state is brought to an issue, in some cases rapidly, and with a 
sudden arrest of its chief symptoms; in others slowly, and by the 
gradual cessation or wearing out, as it were, of the principal phe- 
nomena. The former mode of termination is that known as crisis ; 
the essential characteristic of which seems to be a more or less 
copious evacuation from the system, either through the ordinary 
channels or through some unusual one. The most frequent mode 
of termination of the pyrexial action is by the sudden occurrence 
of a copious and universal sweat. The dry and hot skin becomes 
soft and relaxed, the cutaneous pores expand, and a general dia- 
phoresis is established, which may last for hours, or even the 
better part of a day (or night), and during which a large amount 



TERMINATION BY CRISIS. 57 

of fluid is drained off from the system. Drops of perspiration 
stand out upon the skin, and little streamlets may be observed 
to course along the surface. The patient's night-dress, the bed- 
clothes, and bed become. saturated with moisture, and in extreme 
cases water trickles through the bed upon the floor, where it 
collects in small but visible pools. It is impossible to calculate 
accurately the amount of fluid thus drained off by the skin, 
which in some cases must be very great, and it is always con- 
siderable when marked relief of the pyrexial symptoms is to be 
anticipated. 

During or after the sweat the patient drops quietly asleep, and 
perhaps now, for the first time for many days, gets some hours 
of tranquil and refreshing rest. He awakes a new man, free from 
all fever, feeling cool, refreshed, and invigorated ; the nervous 
depression and vascular excitement are gone, he sits up in the 
bed, craves for food, and but for the debility which commonly 
remains behind for some days, shows little traces of his late ill- 
ness. 

Such is the course of things in a case terminating favorably 
with crisis by sweating. 

In other instances the same end is attained by an unusually- 
free flow of urine, highly charged with salts, urea, and organic 
matter in other forms. 

A smart attack of diarrhoea occasionally seems the mode in 
which crisis is brought about. In still rarer cases the sudden 
occurrence of a hemorrhage from the nose, mouth, urethra, or 
anus, is attended with marked relief of the febrile symptoms, and 
is consequently, regarded as a mode in which crisis may occur. 

Termination by crisis, in the manner just indicated, is to be 
regarded as a usual, but by no means constant occurrence. The 
older writers paid the most minute attention to the subject of 
critical days ; and from their works we may gather that crisis 
was the all but universal mode of termination of the fevers of 
their day. In a very considerable number of cases now to be 
met with, there appears to be no distinct crisis, and the pyrexial 
action gradually subsides. 

Such is a general outline of the ordinary course of a case of 
simple continued fever. It is usually a disease free from posi- 
tive danger to life, but may present complications of a formidable 
kind. It is at all times an affection requiring judicious care and 



58 SYNOCHA. 

management on the part of the physician. The therapeutics of 
continued fever may be best considered after we shall have studied 
other varieties of the disease. 



SYNOCHA. 

Synochal Angiotenic, or Inflammatory fever, is described by 
the older authors as a disease of uncertain duration ; thus we 
meet with varieties of it designated ephemeral, and in which crisis 
seems to have been established on the second, third, fourth, or 
fifth day. Pinel says it may terminate in twenty-four to forty- 
eight hours, or go on to the fourth, seventh, ninth, eleventh, or 
fourteenth day. There is some reason to believe that the pyrexial 
reaction attendant on obscure internal inflammations was not in- 
frequently taken for an essential fever, at a time when the diag- 
nosis of the inflammatory lesions of the great cavities was less 
advanced than it is at present. On the other hand, we cannot 
accept the wholesale reversion of the concurrent opinion of ages 
implied in the rejection of synocha, or inflammatory fever, from 
the category of true fevers ; nor can we agree with the arrogant 
assumptions of the French school, that a gastro-enterite will ex- 
plain all the phenomena of epidemics denoted at various times 
and by very different authors as synocha. 

The followers of Broussais, not content with regarding the 
fevers presented to their own eyes as caused by a gastro- enteritis, 
aspired to pass a chastening hand over the works of the great 
fathers of medicine, from the days of Hippocrates to the most 
recent times, and to interpret with the light of a new pathology, 
not alone the hypotheses, but the facts and observations of all 
past schools and time. To this age of sceptics and doctrinaires, 
however, has succeeded a class of observers who, with not less 
strict and rational views of medicine, unite a more just considera- 
tion and respect for what has been left to us by the master-minds 
of our art from a past day. 

Predisposing causes of Synocha. — The following are the occa- 
sional and predisposing causes assigned by Pinel and others for 
the production of inflammatory fever : youth, the period of 
puberty, sanguine temperament, plethora, period of first men- 
struation, gestation, childbirth, considerable wounds or injuries, 
warm and dry, or cold and dry atmosphere, winter, spring, ex- 



GENERAL CHAEACTERS OF SYNOCHA. 59 

posure to the sun, sudden change from heat to cold, abuse of 
stimulants, excess in food, habitual use of succulent aliments, 
change in mode of life, unwonted physical or mental exertion, 
suppression of hemorrhages, retention of the menses, strong pas- 
sion, love carried to excess, reverse of fortune, and accidental 
causes, such as result from peculiarity of dwelling-place, occupa- 
tions like that of a baker or fireman, residence in hot climates, 
and exposure to certain winds, the north in one locality, the east 
in another. 

Synocha is a form of continued fever of which we meet but 
few well-marked examples in the present day. Some persons 
have even gone so far as to doubt altogether the existence of any 
distinct type of fever corresponding to that described by the older 
writers under the term Synocha. This is, however, in my opinion, 
pushing scepticism too far ; it cannot be argued, that because we 
do not find disease in the present day to correspond with the ac- 
counts of it transmitted to us by the older authors of medicine, 
no such type of morbid action has existed at a former time, or 
may not exist under circumstances other than those with which 
our own limited experience brings us in contact. For myself, I 
can only say, that I see no reason to doubt of the existence of 
synochal fever ; I have met with it from time to time in this 
country, and I have seen well-marked examples of it in southern 
and eastern Europe. 

Synocha has perhaps never been a fever largely prevalent in 
these countries. McBride, than who there can be no better au- 
thority, while he does not deny the existence of synocha, says 
that inflammatory fever was rare in Ireland in his day. 

Synocha, or inflammatory fever, may be described as a disease 
having well-marked periods of rigors ; the pain in the back, 
headache, and the sensations in the extremities, which are well 
and briefly described by the French under the term brisement des 
membres, are usually well marked; these latter sensations are 
what our patients endeavor to describe, when they speak of feel- 
ing as if soundly beaten all over with a stick. This stage, of 
course, varies much in duration, as well as in the severity of its 
symptoms, but it is usually succeeded by a state of pyrexia! re- 
action within twenty-four hours, not counting of course the period 
of incubation, or that during which the patient is said to be 
breeding the disease. This period, as we know, may extend over 



60 SYNOCHA. 

two, three, or more days before the actual commencement of 
rigors, and during this time (that of incubation) the patient may 
complain only of those indistinct and ill-defined sensations known 
as malaise, and which imply general lassitude, impairment of 
mental and bodily powers, and incapacity for the ordinary avoca- 
tions of life. 

The pyrexial reaction in synocha is usually very intense and 
rapidly developed ; the pain, heat, and throbbing in the temples 
are excessive, the surface of the skin generally is parched, and 
gives the sensation of burning and biting heat known as color 
mordax. 

The phenomena presented in cases of this kind are very numer- 
ous and various, and they may implicate almost all the organs 
and functions in the body ; they may be more in one case and 
less in another, they may all coexist with uniform intensity, or 
one set of them may preponderate to the almost total exclusion 
of the rest. Each individual case, it can be readily conceived, 
will take its special character and importance from the aggra- 
vation or preponderance of two or more of the several sets of 
phenomena which we are about to consider. Now, instead of 
regarding the several phenomena presented in the case of synochal 
fever as a chance medley, as is too commonly done, let us see if 
we cannot reduce them to some simple order, consistent with a 
rational pathology of fever. This, it will be subsequently seen, 
is not merely a matter of scientific interest, but will much aid us 
in the selection of appropriate therapeutical remedies when we 
come to speak of the treatment of the disease. The principal 
symptoms may be classified as follows : — 

I. Symptoms referable to deranged states of the nervous sys- 
tem, and including the phenomena of rigors, pains in the back 
and limbs, headache, giddiness, indistinctness of vision, intoler- 
ance of light, pains in the eyeball, in the forehead or occiput, 
sleeplessness, restlessness, and delirium. 

II. Symptoms referable to the circulating system, including 
quick, full, hard, and sometimes vibrating and bounding pulse, 
general vascular reaction, giving rise to increased temperature in 
both external and internal parts, the thermometer in the mouth, 
axilla, groin, anus, or vagina, standing at 103°, 104°, or 105°, 
Fahr., and possibly, in extreme cases, two or three degrees higher. 
Flushings of the face, throbbing of the temples, violent irritative 



PATHOLOGY OF SYNOCHA. 61 

action of the heart, occasionally of the carotids, likewise belong 
to this set of symptoms. 

III. Symptoms referable to derangements of the primce vice, 
including more particularly those due to morbid states of the 
buccal, lingual, gastric, and intestinal mucous surfaces. Under 
this last head are comprised the several varieties of foul and 
coated tongue, nausea, vomiting, gastric anxiety, pain and ten- 
derness, and those irritative states of the mucous membrane of the 
large and small intestines, and which, on the one hand, give rise 
to constipation, flatulence and tormina, and on the other, to some 
form of diarrhoea. 

IV. Symptoms which may be referred to increased action of 
the excretory organs ; these, in a general way, embrace the phe- 
nomena of excretion, by the* cutaneous system, the pulmonary 
surface, the gastro-intestinal mucous surface, and lastly, and, in 
some respects, most important of all, the renal excretory appa- 
ratus. Under this last head we have to consider the several 
conditions presented by the urinary secretion, as to increase or 
diminution in quantity, density, and the relative or positive 
amount of its ordinary ingredients, or it may be of elemtnts not 
usually eliminated through this channel. The whole of this set 
of phenomena acquires an importance, and must receive an inter- 
pretation at our hands quite different from that usually assigned 
to them. It will be seen that from the view we have taken of 
the general pathology of febrile action, the increased metamor- 
phoses of the tissues, or, in other words, more active wear and 
tear of the animal machinery, lead necessarily to increased con- 
sumption of the various constituents of the tissues of the body, 
which, as in the case of machines in the ordinary world, must 
find a visible and tangible representation. 

This representation of the wear and tear of the animal system 
in fevers is to be found, as we have shown, in visible, tangible, 
and even ponderable form, in the increased excretory matter 
thrown off from the various emunctory organs, such as the skin, 
pulmonary and intestinal surfaces, and such organs as the kid- 
neys. 1 

1 It may seem that the reiteration of the views here urged with respect to 
the pathology of fevers is continued almost usque ad nauseam ; but the writer 
believes strongly in the necessity of keeping these doctrines perpetually in view, 
if we desire to interpret rationally, and in the relation of cause and effect, the 



62 SYNOCHA. 

We have stated that the phenomena of synocbal fever are 
usually developed with great intensity and with remarkable 
rapidity. Without confining ourselves to any narrow or stereo- 
typed view of the disease, it will be found that the course of a 
synocha or inflammatory fever presents a natural and obvious 
division into three distinct periods or stages; that of rigors, that 
of pyrexial reaction, and that of the crisis or termination of the 
disease. The first stage is that of rigors, with cutis anserina, 
shrivelling of the fingers, diminished temperature in external 
parts to one or two degrees, as indicated by the thermometer, 
and sensations of more severe cold on the part of the patient, 
great scantiness of the urine, or partial suppression of this secre- 
tion, with headache, pain in the back, and many other phenomena 
due to diminished or paralyzed innervation, and which, as we 
have before explained, vary much in different cases. The second 
stage is that of pyrexial reaction, in which there is evidence of 
great vascular excitement, and the system is, for the time being, 
so to speak, acting above par, and may be compared to a machine 
working at high pressure speed, and thus by the increased fric- 
tion, oi*wear and tear of its component parts, endangering the 
safety of the whole. It is at this period that we find most 
severely complained of such symptoms as heat, intolerance of 
light, headache, throbbing of the temples, and excessive action 
of the heart, carotids, or other parts of the vascular system, with 
delirium at night, sleeplessness, and violent efforts to get out of 
bed ; these efforts often call for personal restraint, as they tend 
to wear out and exhaust the patient, and often leave him in a 
state of great prostration ; all restraint in such cases, however, 
must be used with judgment and discretion, and while it is firm, 
must be devoid of unnecessary rudeness or violence. The dura- 
tion of this stage is not very positively defined; it may last five, 
seven, or ten days, during which vascular action continues una- 
bated, and the pulse may present fulness, hardness, and great 
reaction against the finger, for nearly the whole of this period. 
Attendance on cases of this kind often presents grave anxiety 
for the junior physician, and though not on the whole formidable 

several complicated phenomena presented in the course of an ordinary fever. 
It is also desired that, if any section of this work he studied separately (as so 
often happens with works of the kind), the reader may not fail to receive full 
and just notions of the general pathology of fever. 



PATHOLOGY OF SYNOCHA. 63 

cases, for the proportion of mortality which they present is not 
very large, they sometimes prove fatal in a manner for which 
the junior physician is not prepared. Those cases in which the 
head symptoms preponderate, with throbbing of the temples, 
violent headache, delirium, and sleeplessness, are not infrequently 
regarded by the public as "brain fever" a name fraught with 
every conceivable association of horror and fatality. Erroneous 
impressions of this kind are pardonable enough on the part of 
anxious and interested friends, but what shall we say of the 
ignorance or slothfulness of some physicians, who still allow 
themselves to be influenced by such pathological mystifications, 
and whose experience of disease seems to be drawn from the 
crude theories of the public, rather than from the exact results 
of pathological investigations. It is true that Clutterbuck, a 
man of no mean name and authority in his own day, regarded 
synocha or inflammatory fever as having its anatomical seat in a 
phrenitis, or inflammation of the brain. Within our own day, 
Bouillaud considered this fever as the result of an angio carditis, 
or general inflammation of the lining membrane of the heart 
and great vessels. Now, if we appeal to pathological experience, 
is there any evidence that the head symptoms, which present 
themselves in the course of the synochal or other fever, depend 
upon any state of inflammation of the cerebrum or its mem- 
branes? Doubtless we shall find in some cases that, both during 
life and after death, unequivocal proof of the inflammation of the 
brain or its appendages shall be present in synochal as well as in 
other fevers; when present, however, such affections are only 
examples of the occasional, inconstant, secondary lesions, which 
occur now in this organ, now in that. That such a symptom as 
delirium is no evidence of inflammation of the brain in the 
course of a fever, is well shown by the following results obtained 
by Louis. 

* Of twelve fatal cases of fever in which, during life, no delirium 
or other prominent head symptom had been observed, the brain 
was found to be perfectly healthy in six on post-mortem exami- 
nation ; in four the cerebral substance was red, and in two the 
brain was slightly softened ; that is to say, that in half the cases 
presenting no delirium or other prominent head symptom during 
life, there was found, post-mortem, a slight departure from the 
healthy state of the brain. In twelve other cases, which pre- 



64 SYNOCHA. 

sented delirium and other prominent "head symptoms, five ex- 
hibited, on post-mortem examination, a perfectly normal condition 
of the brain and its membranes; in five there was slight redness 
of the brain ; in one, slight injection ; and in one, slight softening : 
that is to say, in twelve cases, all presenting delirium, nearly 
half showed no trace of anatomical lesion of an inflammatory 
kind, or otherwise, to account for the symptoms during life. It 
is a legitimate conclusion from these statistics, that delirium and 
inflammation of the brain have no necessary connection with each 
other in fever, that we cannot argue from the presence of the one 
to the existence of the other, and that we are not warranted, in 
employing the treatment appropriate to inflammation of the brain 
or its membrane in cases of fever with delirium. 

With these results before us, we must be slow to regard throb- 
bing of the temples, heat and flushings of the head and face, pain 
in the eyeballs and forehead, intolerance of light, sleeplessness, 
and delirium, as indicative of inflammation of the brain ; and we 
must be equally slow to bleed, purge, or otherwise lower the 
system in cases presenting such phenomena. We know from 
experience that antiphlogistic treatment will not answer in these 
cases, and that for two reasons: first, it will not relieve, and may 
possibly aggravate such symptoms as we have above detailed; in 
the second place, and this holds especialty with regard to the 
cases we meet in these countries, depletory measures often un- 
questionably tend to lower the tone of diseased action, without 
putting an end to it, and to convert a well-developed sthenic 
pyrexia, having little of real danger about it, into a condition of 
low typhoid action, with great sinking of the vital powers, and 
from which it will be impossible, at a subsequent stage, to save 
the patient, by even the most bold and unlimited use of stimu- 
lants. 

The phenomena which we meet in cases of synochal fever, re- 
ferable to the circulating system, are often well marked. They 
comprise, as already stated, violent cardiac action, sometimes to 
the extent of strongly vibratile or pounding pulsation of the 
ventricles, the shock of which is painfully felt by the patient 
himself throughout the chest, and in the vessels of the head and 
neck. In extreme cases of this kind the force and tension of the 
whole vascular system are raised to an extraordinary degree. 
The patient is in a highly irritable state, and complains of intense 



BLOOD-LETTING IN SYNOCHA. 65 

heat, and a bursting sensation in the head, body, and extremities. 
Color mordax is present to a marked degree; the eyes assume 
a glistening, fierce, and ardent expression, the cheek bones are 
suffused with a bright scarlet tinge, the palms of the hands and 
the soles of the feet are parched and burning to the patient's 
feelings, and indicate positive increase of temperature to the 
physician's hand or thermometer. Heat is the dominant charac- 
teristic of this state, and this is the condition which best realizes 
for us the xaixus, or febris ardens, of the Greek and Latin authors. 

There is usually no relief to these symptoms, often extremely 
distressing, until a copious sweat supervenes spontaneously, or is 
brought about by the action of diaphoretic medicines. The pulse 
is usually about 120 in the minute ; it is full, sometimes hard, and 
often bounding under the fingers; it resists compression, and 
even when pressed with much force by the fingers, it is with 
difficulty entirely obliterated, the part of the vessel immediately 
above the point of the vessel impinging forcibly against the finger, 
with that kind of action which we denote by saying, "the pulse 
has got a kick in it." It is well worthy of remark that in the 
class of cases now under consideration, the force and tension of 
the vascular system are uniform throughout the whole of the cir- 
culating apparatus ; thus, if the heart be acting with violent 
throbbing pulsation, the carotids, radials, and femorals will be 
found acting with corresponding force and volume. We have 
not, then, in synochal fevers — and this is to the experienced phy- 
sician an important indication for prognosis — that remarkable 
contrast between the force and volume of the pulse and the car- 
diac impulses, which we know to be of such frequent occurrence 
and such bad augury in the typhous types of fever. 

It is undoubtedly to this excited state of the vascular system 
in synochal fevers that we must trace the origin of depletion by 
bleeding in this class of cases. It seems no unnatural conclusion 
to think that there is too much blood in the system, when we 
find the vessels in all parts of the body within our reach of appa- 
rently increased volume, and acting with more than redoubled 
energy; and when we also have so many other presumable evi- 
dences of disturbances in the equilibrium of the blood's circula- 
tion, coupled with apparent increase in quantity as well as of 
change in quality of the circulating fluid. It was an obvious 
conclusion, but one based upon superficial analogy and erroneous 
5 



QQ SYNOCHA. 

pathology, to believe that by reducing the amount of the blood 
in circulation in the vessels, by abstracting one or two pints 
directly from a vein, we could control the diseased state and 
correct the morbid process going on in the system. It is expe- 
rience alone that could supply an irrefutable answer to such 
plausible a priori reasoning. The best practitioners are now satis- 
fied, from the results of experience, that abstraction of blood by 
general venesection will not answer the purposes intended. Now 
we do not mean to contend that venesection is not applicable and 
useful in certain cases, but, as rational pathologists, we cannot 
admit that venesection will cure a fever in the only way, and in 
the only sense, in which we conceive that such an operation can 
be effected. Fever, in our views, implies increased action in all 
parts of the system, the vascular apparatus included ; it implies 
increased wear and tear of the tissues, and the production of a 
greater quantity of effete material, resulting from the increased 
metamorphosis of the tissues. To cure the fever, nature or art 
can employ but one means, viz. to carry off from the system, 
through one or more of the emunctory channels, the effete mate- 
rials above indicated. It will be said that these effete materials 
find their way into the blood in the first instance, and that in this 
way we have a direct means of eliminating them from the body 
by the process of venesection. This, no doubt, would be true, if 
we could abstract by bleeding all the impure and contaminated 
blood, and throw into the patient's veins and arteries a new, pure, 
and healthy blood to replace his own. But it will be seen at 
once, that in withdrawing by venesection a pound or so of blood, 
we are really only eliminating about a thirtieth part of the im- 
pure and effete material which has found its way into the circula- 
tion. This argument, if followed to its legitimate logical conclu- 
sion, must satisfy any rational pathologist that venesection, how- 
ever extensive, can never be anything more than a very partial 
and imperfect means of getting rid of the chief results which 
febrile action produces in the system. As a depurative and 
eliminative agency, it cannot be for a moment compared to such 
a general and extensive one as that performed in the progress of 
sweating, continued for even a very few hours. Nor, again, is 
the efficacy of venesection in this respect at all comparable with 
that of an eliminative function, such as is performed by the kid- 
neys in the course of two or three hours. 



BLOOD-LETTING IN SYNOCHA. 67 

In the case of a surface like that of the pulmonary membrane, 
that of the intestines, that of the skin, or that of the kidneys, the 
whole mass of the circulating blood passes and repasses over and 
over again upon a sieve-like apparatus, which admits of the 
transudation of the effete and noxious materials from the blood 
stream. Under these circumstances the course of the blood, sur- 
charged, with the effete materials produced by the consumption 
of the tissues in fevers, may be compared to a stream which, im- 
pregnated with earthy particles, silt, and other impurities, deposits 
them in various points of its course, and then flows on pure and 
limpid. Such analogies as these must, however, not be pushed 
too far: the lungs eliminating carbonic acid and hydrogen; the 
skin throwing off water, salts, ammonia, and other compounds ; 
the kidneys carrying off urea, uric acid, chlorides, sulphur, phos- 
phates, and their allied bases ; and the intestinal canal acting as 
the common sewer of the system, play the part of so many strainers 
or purifiers. We must not forget, however, that in a highly com- 
plicated machine like the animal body, each part reacts upon all 
the others, and the blood itself, when rendered impure, will in its 
turn influence the nervous centres, which stimulate the vascular 
system and the other parts engaged in the febrile process. It is 
under this view that venesection may be defended when employed 
with the object of lessening the amount of stimulant fluid, "impure 
fluid," which is reacting on the nervous centres, and thus adding 
fuel to the fire, and keeping up the cycle of pyrexial actions. 
We do not deny, then, that there are cases in which a bold and. 
early venesection may have the effect of partially arresting the 
process of febrile actions, or of preventing them from spreading 
to a wider circle of parts. Mark, however, that in this aspect 
bleeding answers but one purpose ; it may control, but it cannot 
cure the fever. Febrile action, if continued only for an hour, 
produces effete material, as the burning of coal or wood produces 
ashes. The pathological or febrile ashes must be eliminated from 
the system : bleeding cannot, in any conceivable way, effect this 
object; it can only be accomplished by elimination through the 
pulmonary surface, the skin, the intestines, or the kidneys, acting 
singly or in combination. 

The third period of a synochal fever is that in which a lysis, or 
solution or termination of the disease, is brought about, either by 
the spontaneous efforts of nature or by the agency of medicine. 



68 SYNOCHA. 

It is not at all unusual to find that, in the present day, febrile 
diseases come to an issue by a gradual fading and diminution of 
the symptoms one by one. It is probable that in these cases a 
slow but regular elimination of the various effete materials pro- 
duced by the febrile action takes place in an almost insensible 
manner, the process being extended over many days. We can 
readily suppose that at a certain period of a fever, when effete 
materials are accumulated to a certain extent, the several emunc- 
tory organs, such as the pulmonary surface, skin, intestinal and 
renal apparatus, begin to eliminate, with a slightly increased ac- 
tivity, and, after the lapse of a few days, silently but effectively 
throw off from the system the materia peccans. What shall we 
say of the doings of the ignorant physician, who, incapable of 
understanding the delicate play and nice balance of the finely 
adjusted animal mechanism, by his meddling interference and 
blundering nostrums, disturbs the equilibrium of the various 
organs, arrests or paralyzes the activity of one, or suspends the 
functions of all. And yet, in no class of cases more than in 
fevers, do we find injurious effects from the nimia diligentia medici 
In marked contrast to this gradual and silent subsidence, as it 
were, of the febrile actions, we find another mode, in which they 
are brought to a termination in a rapid and striking manner, by 
the process known as crisis. We leave a case to-day in a condi- 
tion of delirium and full pyrexial reaction, with high nervous 
excitement, the vascular system in a state of extreme tension, the 
skin hot, and all the symptoms of ardent fever well marked. 
And yet a few hours may restore the patient to a state of almost 
complete convalescence, with general tranquillity of the system, 
clear intellect, cool skin, the pulse at its natural standard, and 
all parts performing their functions in a perfectly healthy manner. 
The pathological explanation of this process is, that a sudden, 
copious, and complete elimination of effete material has been 
brought about by one or two or more channels : thus we shall 
find that the patient has been affected with a most abundant dia- 
phoresis ; or that a smart diarrhoea has survened; or again, an 
excessive deposit has taken place in the urinary secretion. In 
other cases a lysis or crisis of the disease seems to be brought 
about by the occurrence of a hemorrhage from some particular 
part or organ. In this way we find, occasionally, that an epis- 
taxis, or bleeding from the nose, or again, a transudation of blood 



MODES OF TERMINATION IN SYNOCHA. 69 

from the intestinal mucous surface, is attended by relief of all 
the febrile symptoms, and seems to take the part of a true crisis. 
Much attention was paid by the older physicians to the subject 
of crisis, and with them it played a far more important part than 
our experience warrants us in assigning to it in the present day. 
The doctrine of critical days has been a much vexed question in 
the schools. Fever was supposed to be a diseased action, obey- 
ing certain laws of periodicity with a precision truly marvellous. 
The tendency to a natural issue of the disease by crisis, on cer- 
tain days, was regarded as a kind of morbid law in the system. 
Certain days from the commencement of the disease were espe- 
cially regarded as critical, and if the crisis by sweat, urinary 
deposit, or diarrhoea did not fall exactly upon an orthodox critical 
day, there was much temptation to ante-date or post-date the 
commencement of the disease, and thus to make facts square with 
theory. The most favorite critical days were the 5th, 7th, 11th, 
14th ; and 21st. "We are far from denying that at certain periods 
febrile disease presents an unmistakable tendency to terminate on 
critical days; but we think that it is consistent with observation 
to state that a critical issue of fever, and the sudden termination 
of pyrexial symptoms, after a process of sweating, diarrhoea, in- 
creased urinary elimination, or accidental mucous hemorrhage, 
is far less common in our day than it once was. 

In a clinical point of view, synocha is to be regarded, when it 
presents itself to our view in the present day, as a type of pyrexia, 
in which the system is acting above par, the fever is high, the 
nervous and vascular tension is sustained throughout, and there 
is an absence of any tendency to sinking and death by asthenia. 
In this regard synocha is divided by a broad line of demarcation 
from fevers of the typhous type. The febrile action is higher in 
synocha than in the common continued fever ; the duration of 
synocha is likewise less than that of the latter disease; its ordi- 
nary period seems to be from ten to fourteen days. Cases in which 
synochal fever is developed with intensity, present much anxiety 
to the physician ; a fatal issue, though not common, must be 
borne in mind as a very possible occurrence; the assemblage of 
symptoms presented is often very alarming ; this is especially so 
when we have to deal with patients in whom the head symptoms 
predominate, with delirium, sleeplessness, nervous excitability, 
violent or sledge-hammer pulsation of the heart, and with intense 



70 SYKOCHA. 

heat of skin. How are we to acquit ourselves in cases of this 
kind, when, by the importunities of friends, we are urged to com- 
mit ourselves to a prognosis ? 

Till the junior physician has the responsibility of such a case 
upon his own shoulders, he can little appreciate the gravity of 
such a question as this, plied and replied with all the urgent 
solicitude of an anxious mother or wife, " Doctor, what's your 
opinion of him to-day ; do you think he'll get over it ?" A hap- 
hazard opinion will not do in such a case ; it may compromise 
your character and prospects in one or other of two (to the inex- 
perienced physician) very unexpected ways. The case may be 
brought to a rapid end within forty-eight hours, by the fatal 
effects of uneliminated poison and effete materials upon the sys- 
tem. The vital thread, so highly strung, snaps suddenly from 
excessive tension. If unprepared for such a result, and that an 
incautious opinion betrays your ignorance, you will be a fortunate 
man if the generous public do not lay at your door the responsi- 
bility of such a case. Suppose it to happen in the person of an 
individual of some public station and notoriety in his local circle ; 
and you can understand yourselves what the effects will be. On the 
other hand, what will be your position if you have unnecessarily 
raised alarm amongst parents and relatives, in a case in which an 
unexpected crisis by sweat, diarrhoea, or urinary deposit, brings 
the patient to a state of almost complete convalescence within 
twenty-four hours, and thus gives the lie to your lugubrious 
prognostications of the day before ? 

A sound and reliable opinion is to be formed in fever cases 
only from a full consideration of all the symptoms present, based 
on a rational conception of their true pathological significance* 
Cases in which the action in the system is uniform and well- 
balanced in all the organs and functions, may be regarded as 
comparatively safe ; those, on the other hand, in which there is 
an excessive preponderance of one set of actions, must be viewed 
with suspicion, if not alarm. While all parts of the machine are 
working with uniform pressure, though at a high velocity, its 
safety is not immediately endangered. 

Cases with preponderating and excessive action of the nervous 
system, delirium by day and night, sleeplessness, and violent 
efforts to get out of bed, are full of danger, and till some hours 
of quiet sleep have been obtained, cannot be for a moment re- 



SWEATING IN SYNOCHA. 71 

garded as safe. Cases with violent action of the heart and vessels 
are likewise of a very treacherous character. Cases with hot skin, 
and early and abortive sweats, are likewise often fatal. The 
phenomena of sweating require to be carefully studied. In the 
language of Sydenham, it is only those sweats which are the 
result of " coction " or digestion of the materia morbifica, that are 
available for crisis. Short and early sweats, that is to say, those 
occurring before the seventh day, are seldom effective in lowering 
the rate of the pulse or heat of the skin, and they are often in- 
dicative of mischief to come. Partial sweats, in like manner, as 
those of the head, face, or chest, are seldom favorable, often the 
contrary. 

All practical physicians must be aware of the fact, that sweat- 
ing is not infrequently a symptom of most unfavorable augury 
in all kinds of fevers. This is especially the case with the sweats 
which occur in connection with weakened and accelerated pulse. 
We shall have again to speak of this variety of sweat when 
dealing with typhus. In this form of fever we know that sweat- 
ing, with a pulse rising from 100 to 120, 130, or even 140, is 
about the most unfavorable prognostic with which we are ac- 
quainted. 

In general, it may be said that sweats, which after twelve or 
twenty-four hours are unaccompanied with marked diminution 
of the febrile state, i. e. lesser temperature and pulse rate, are 
hurtful rather than otherwise. We must remember that sweat- 
ing is an essential characteristic, and a very grave and depressing 
complication in rheumatic fever, and in the sweating or miliary 
fever, in which we have it recurring day after day, without 
diminution of the febrile state, and often with great aggravation 
of all the symptoms. We cannot, therefore, regard sweating as 
a curative process per se. And this, be it observed, holds good 
in reference to sweats produced by natural action, and those arti- 
ficially induced, whether therapeutically or not. We often see 
a patient for many hours suffering from fatigue and distressing 
heat attended by sweats, due to the weight of the bedclothes, 
the close atmosphere of his bedroom, or the season of the year ; 
and yet, so far from any cooling effect being produced, we find 
perhaps a nocturnal exacerbation, and the patient for many days 
afterwards in a state of increased pyrexial irritation. We may 



VA SYNOCHA. 

draw from all these considerations the following practical conclu- 
sions : — 

1st. That sweating is not a salutary process, when it occurs 
prematurely, or when it is brought about too early by artificial 
means, such as clothing, confined atmosphere of the room, or, 
again, by therapeutic agents. 

2d. That sweating is to be regarded as a safe and reliable 
therapeutic and curative process only when it forms part of a 
general eliminative action in the system. 

Complications in Synocha. 

Synocha is a fever which does not present any remarkable ten- 
dency to secondary complications. The head symptoms doubtless 
sometimes present great severity, and, as already noted, give the 
preponderating feature to the disease. When such is the case, 
the fever, as before stated, is sure to be regarded as cerebral or 
brain fever, and the doctrines of inflammation have so impressed 
themselves upon the mind of the public and the profession, that 
the well-educated physician often requires great moral courage 
and steadfastness of purpose to abstain from extensive local or 
general venesection in the clamor for depletory measures that 
assails him. We can only again refer to what has been already 
said on this subject. Cases will undoubtedly be met with from 
time to time in which there is a plethora of the cerebral vessels ; 
cases may likewise occasionally be met with in which there is 
true inflammatory action in the brain or its membranes, and 
which must be treated accordingly. 

A set of symptoms referable to the alimentary tract, sometimes 
causes considerable distress in cases of synocha. The tongue is 
very foul, thickly coated, and furred; there is much uneasiness, 
with sense of fulness and distress, if not positive pain, in the epi- 
gastric region ; nausea and vomiting may be present to a marked 
degree, and be a source of great additional suffering. Fulness of 
the abdomen, with various symptoms of intestinal irritation may 
also be present. Many of these symptoms are doubtless to be 
referred to an overloaded state of the intestinal canal at the period 
when the patient was seized by the fever. The foul and furred 
tongue, the status gastricus sabvrralis, or state of the stomach, with 
foul eructations, and the diarrhoea crapulosa of the older authors, 



TKEATMENT OF SYNOCHA. 73 

are to be explained as the result of a salutary effort to get rid of 
ill-digested and fermenting substances which load the alimentary 
canal. 

Treatment of Synocha. 

We are now in a position to take up the consideration, in a 
systematic way, of the therapeutics of synocha or inflammatory 
fever. We have already disposed of some of the considerations 
which affect the question of bleeding in this variety of fever. It 
will have been seen that we are not advocates for indiscriminate 
bleeding, in this or any other kind of fever ; yet we cannot be 
blind to the fact, that in many countries of Europe venesection 
is in common use as the primary means of treating varieties of 
this fever. It might no doubt be logically maintained, that in 
these cases bleeding was only an indifferent remedy, and that 
where robust constitutions, and a type of disease devoid of any 
sinking tendency, are in question, a bleeding to fifteen or sixteen 
ounces has no effect upon the case, one way or other, and that the 
patients are just as little influenced by a bleeding to the above 
extent when in fever, as they are known to be when bled in a 
state of health at certain seasons of the year. As a popular hy- 
gienic means, bleeding has long been in use in many countries in 
the spring time. In cases of synocha, with manifest overaction 
of the vascular system, and determination to the head, bleeding 
from the arm will in certain instances be useful in controlling the 
excitement of the heart and arteries. In the cases which we meet 
in these countries, venesection to the extent of sixteen to twenty 
ounces may be considered as a very reasonable depletion. We 
must ever bear in mind the tendency which our cases so con- 
stantly exhibit to low typhoid action in the secondary periods of 
their course, no matter how sharp and violent the symptoms may 
have been at the outset. However, cases may occur in which 
even a second bleeding may be requisite ; beyond this I should 
deem it hazardous to go, though I am cognizant of the fact, that 
even in fevers of still lower type, venesection has been employed 
with impunity to the extent of fifty ounces in individual cases. 

Leeches to the temples, when there is pain, with heat, and 
throbbing of the head, are decidedly useful ; two, three, or more 
leeches may be applied, according to the urgency of the symp- 



74 SYNOCHA. 

toms : six leeches to each temple will effect what I should regard 
as a full depletion. If I mention bleeding from the temporal 
arteries, it is only to give it my most unqualified condemnation, 
and that for several reasons. Firstly, blood from the temporal 
arteries comes directly from the heart, not from the cranial cavity 
or brain. Secondly, the mechanical difficulties which attend 
efforts to repress bleeding from the temporal arteries, and the 
pathological consequences so often entailed, constitute additional, 
and by no means unimportant objections. In using general and 
local depletion, it will be necessary to watch carefully the effects 
upon the pulse. Diminution in the rate and tension of the pulse, 
and a cooling of the skin, are to be looked on as favorable results. 
Supposing the pulse to range in these cases from 110 to 120, we 
may consider a fall of ten or fifteen beats as an important im- 
pression made upon the disease ; but our indications may more 
safely be drawn from diminution of the force and tension than 
the rate of the arterial beat. These are characters best acquired 
in clinical practice, and by no means easy of description. What 
we are to expect is, that the pulse shall lose any hardness and 
vibratile and jerking character which it may have, and especially 
that particular jerking reaction against the fingers which we have 
called " a kick ;" that it shall become soft, yet retain its natural 
resiliency ; that it shall be uniform and of moderate volume, 
without anything of a hard and cordlike feel. In regard to the 
head symptoms, the pain, heat, throbbing, and other sensations 
will perhaps be best measured by the patient's own feelings. 
Such symptoms as delirium, sleeplessness, the condition of gene- 
ral excitability, and the state of the intellectual faculties, must 
of course be estimated by the physician. The expression of the 
countenance, the characters presented by the eye as to prominence, 
preternatural lustre, or suffusion, or brilliancy, and fixity of gaze, 
mildness, sternness, or ferocity of expression, or the contrary, as 
dulness and vacancy, must all be taken carefully into account ; 
the state of the pupil likewise must be noted as to dilatation or 
contraction. Cold lotions to the head will often be found useful 
in cases of temporary cerebral congestion. Where there is a 
decided preponderance of head symptoms, it may be advisable to 
shave the head, but this is a proceeding that must not be too hastily 
adopted. Cold affusion, especially if water be poured on the head 
from a height, is a powerful means of producing an immediate 



TKEATMENT OF HEAD SYMPTOMS. 75 

impression, but if carried to too great a length, defeats its object 
by inducing excessive reaction. Cooling lotions of various kinds 
have decided effect where there is sensible heat of the head : re- 
frigerating mixtures are still more active ; and the ice-cap ap- 
plied on the shaven crown is a most excellent remedy for severe 
cases. 

The violence of the head symptoms, the wild delirium, and the 
difficulty of restraining the patient in bed, often constitute very 
grave and serious complications. When venesection and leeches 
to the temples fail to give relief in such cases, shaving the head 
and the application of the ice-cap must be tried. Counter-irrita- 
tion to the head by blisters, or otherwise, must be used with great 
caution; such applications sometimes have a stimulant instead of 
a sedative effect. Accident and self-inflicted violence must be 
carefully guarded against in these cases ; I am myself opposed 
to the use of the strait- waistcoat, except when other means en- 
tirely fail to control the patient. While this state of cerebral 
excitement lasts, the patient must not be left alone for a single 
instant by day or by night ; much depends in the management of 
such cases on the vigilance, personal energy, and zeal of a faithful 
nurse. Such an auxiliary is at once invaluable and indispensable ; 
and there are many cases, both in hospital and private practice, 
in which it would be rash, if not impossible, for the physician to 
combat disease without the aid of an experienced nurse. The 
delirious patient in fever is often controllable by the personal 
energies of his nurse, and made amenable to her commands to a 
remarkable degree ; she plays a part only second to that of the phy- 
sician . 

Arrosion with a watering-pot has been practised in cases with 
violent head symptoms ; the external use of water, or wet cloths 
applied to the surface, is undoubtedly a powerful therapeutic 
means. We cannot, however, enter here into a discussion of 
hydropathic therapeutics ; we do not deny the efficacy of such 
means, so far as they go, but what cannot be controverted is, that 
while increased cutaneous elimination is the chief if not exclu- 
sive result of hydropathic agencies, it answers only one of the 
many ends which must be met to cure such a general systemic 
process as fever. 

The use of emetics has had an extensive vogue, both in past 
and recent times, for the cure of this class of fevers ; it has even 



76 SYNOCHA. 

been thought that the effect of emetics was still more energetic, 
and that it was possible by their action to cut short the febrile 
process. It was conceived by the advocates of this view, that in 
this manner a kind of abortion of the febrile state could be effected. 
There can be no doubt that a strong emetic of the potassio-tar- 
trate of antimony, sulphate of zinc, ipecacuanha, or mustard, may 
give a powerful revulsion to the nervous system through the 
gastric filaments of the vagi ; and it may be that in the minor 
febrile states it will be found possible to arrest the pyrexial action 
by such means. However, that emetics may be effectual to pro- 
duce this arrest or abortion of the febrile state, they must be 
administered at the earliest possible moment, and before the com- 
plicated train of actions which constitute fever is established. It 
is extremely rarely that we meet with cases in the nick of time, 
to use emetics with the above intent ; more commonly the febrile 
state is well set up, if not fully established, when the physician 
is called in, At such a period emetics can have only a minor 
object in view, that of unloading the stomach of any crude ingesta 
that it may still retain. 

Experience shows us that emetics used at this juncture gene- 
rally produce only distressing vomiting, gastric irritation, and it 
may be a state of subacute gastritis, with incapacity of retaining 
food or medicine, all which symptoms tend much to complicate 
the case, and to render the subsequent progress of it very often 
troublesome and sometimes hazardous. It will be in the recol- 
lection of almost every practical physician, that he has seen cases 
in which obstinate gastric irritation and incapacity of retaining 
food or medicine have been directly traceable to the abuse of the 
emetic treatment of fevers. It is not to be argued from anything 
here stated that the use of emetics is condemned without qualifi- 
cation. Emetics are useful in this class of fevers when the cases 
are seen very early, that is, before the full development of the 
pyrexial state, and when administered with caution. 

The use of purgatives has been at all times much favored by 
the advocates of the antiphlogistic plan of treatment in fevers. 
Some practitioners have looked to purgation as only next in 
importance to bleeding, and the two methods of treatment have 
commonly gone hand in hand ; there have, however, been those 
who regarded the clearing out of the primce vice, and the estab- 
lishment of a copious drain upon the system, through this exten- 



PRACTICAL RULES. 77 

sive channel, as the exclusive means by which fever must be 
eliminated from the system: the Hamiltonian method, in fact, 
took the place in a former day of the hydropathic system of the 
present; the one insisted as stoutly upon the all-sufficiency of 
intestinal elimination, as the other upon that through the skin. 
Cases will undoubtedly occur, in which purgation is the most 
obvious as well as necessary therapeutic indication to be followed 
in the first instance ; but no practitioner of any experience can 
have failed to meet with cases in which excessive purgation has 
been productive of the most injurious effects. We meet with 
cases in which diarrhoea, tormina, flatulence, and tympanitis seem 
to be the result of purgatives injudiciously administered in the 
outset of the case. There is, in fact, no way in which cases are 
more commonly perverted from their natural course, and, to use 
a vernacular term, "spoiled," than by the injudicious use of pur- 
gatives at the commencement; while the cases in which an arrest 
or abortion of the fever is effected by these means are infinitely 
less frequent, even than those in which bleeding and emetics 
prove effectual. 

Having passed in review the chief principal modes of treatment 
which have found favor in cases of synochal fever, we may now 
give a summary exposition of the therapeutic plan we think 
applicable to this class of cases. 

1st. Yenesection is occasionally called for; its therapeutic indi- 
cation is to control the vascular excitement, which, reacting in its 
turn on the nervous system, tends to keep up and increase the 
febrile state. In these countries, synochal fever, rarely a pre- 
dominant type, still more rarely calls for excessive depletory 
measures. One bleeding, or at most a second to the extent of 
about thirty ounces in all, may be taken as the limit of depletion 
in the synocha of these countries. In dealing with this type of 
fever as met with elsewhere, we must be guided by the circum- 
stances under which it occurs, and the epidemic constitution of 
the time and place where it is met with. Local depletion by 
leeches to the head may be more boldly used. 

2d. While we do not desire to establish an excessive action of 
the stomach, intestinal canal, kidneys, or skin, we must bear in 
mind that the cure of synochal fever, as well as that of other types 
of pyrexial action, depends upon the complete elimination from 
the system of the morbid matters and effete materials resulting 



78 SYNOCHA. 

from the increased wear and tear of the tissues which occur in 
fever. We have consequently to look for, if not artificially pro- 
duce, increased action of the pulmonary and intestinal surfaces 
and the cutaneous and renal functions. It is in this view that 
the use of neutral saline medicines, diaphoretics, purgatives, 
emetics, and occasionally diuretics forms part of a rational sys- 
tem of therapeutics in fevers, which recommends itself to con- 
sideration by the reasonable adaptation of the means employed 
to the ends to be accomplished. 

3d. The following practical rules are deduced from the obser- 
vations of the older physicians ; they considered that symptoms 
about the head, with pains in the neck, back, and down the arms, 
alternation of heat and cold, with giddiness, loss of sight, oppres- 
sion of the chest and epigastrium, indicated gastric overloading, 
and called for means directed thereto. Symptoms about the loins, 
with pains in the small of the back, faintness and weariness in the 
lower limbs, alternately hot and cold feet, with distension of the 
belly, gripes, foul tongue, mouth bitter, hot, and fetid, indicated 
an overloaded state of the lower part of the alimentary tract. The 
former symptoms, when present in a marked degree, are a proper 
indication for emetics, the latter for, purgatives ; both, however 
must be used with caution and discrimination. With regard to 
emetics, we have to choose from those already indicated ; but our 
selection must not be made at random. A teaspoonful of mus- 
tard, a scruple of ipecacuanha, or a scruple of sulphate of zinc, 
may be employed to produce an immediate unloading of the sto- 
mach, where no further object is desired. The action of the fore- 
going drugs may be rendered more effective by causing the patient 
to drink a cupful or two of hot water. Where, however, it is 
desired, besides unloading the stomach, to produce an impression 
on the nervous system or pulse, and at the same time to act upon 
the skin, tartar emetic must be exhibited. From a quarter to 
half a grain, or in very extreme cases a grain, of tartar emetic 
may be given at once, dissolved in an ounce of water ; free vomit- 
ing perhaps of bilious matter, and sometimes a purgative effect, 
may be expected after a second or third quarter or half grain 
dose ; we may also look for a softening of the skin and a com- 
mencement of diaphoresis, with a slight but sensible diminution 
of the force and frequency of the pulse. The fulness and heat of 
the head and throbbing of the temples, as well as the excessive 



USE AND ABUSE OF DIAPHORETICS. 79 

action of the heart, will be diminished to some considerable de- 
gree if the drug is acting favorably. We must never forget, how- 
ever, in using tartar emetic in fever, that we are dealing with a 
two-edged weapon ; and I feel that I cannot be too cautious when 
speaking of its employment at all in these cases. My own opinion 
is, that the instances are rare in which it can be used with marked 
effect of a beneficial kind; on the other hand, we know that eme- 
tics in any shape often induce most troublesome gastric compli- 
cations in fever. 

Diaphoretics in Fever. 

Sudorifics have entered largely into the treatment of fevers at 
all times; they are an admirable adjunct to other treatment, but 
are constantly much abused. Both the hot and cold bath, arro- 
sion with cold water, and the more elaborate processes of the hy- 
dropathic system, including packing in the wet sheet, are much 
vaunted as agencies to promote copious transudation from the 
skin ; but no exclusive means of treatment can be accepted by 
the physician well versed in the pathology of fever. With a hot 
and dry skin, and consequent restless excitement on the part of 
the patient, relief will be given perhaps most readily by acting 
on the skin and inducing a general moderate and continuous 
sweat ; but we must be careful not to disturb the equilibrium of 
the system, or to derange the action of the internal organs. Tar 
tar emetic, James' powder, the antimonial powder of the Pharma 
copoeia ; ipecacuanha, the citrate, acetate, and nitrate of potash 
the spirits of nitrous ether ; the liquor etheris oleosus, or Hoff- 
mann's anodyne ; and, lastly, warm drinks, such as whey, gruel 
barley-water, and meal tea, with a grain or two of hippo or nitre, 
and increased clothing, give us abundant means to choose from 
for inducing moderate and continuous diaphoresis. An excellent 
combination is that of two to four ounces of Mindererus' spirit 
(aqua ammonise acetatis), with two drachms or half an ounce of 
the spirits of nitrous ether, with as much water or camphor mix- 
ture as will make up an eight ounce mixture. To this may be 
added from one to two grains of tartar emetic, according to cir- 
cumstances, and the mixture may be administered in tablespoon- 
fuls, or ounce doses, as the symptoms seem to require. Now, 
what we have to keep in view is the production of a gentle, 
uniform, and continuous diaphoresis ; we have already sufficiently 



80 SYNOCHA. 

exposed the fallacy of endeavoring to sweat the patient out of his 
fever. James' powder is undoubtedly a useful remedy for the 
purpose here indicated, its active principle is probably identical 
with tartarized antimony, and, like this latter, if used in excess, it 
may produce gastric irritation. The pulvis Jacobi veri may be 
given in doses of from one to two or three grains every second, 
third, or fourth hour during the day, or in a single dose it may 
be given the last thing at night in a .somewhat larger quantity ; 
thus we may give from four to five grains in pill or powder at 
bedtime, and to this may be added occasionally a grain or two of 
the extract of hyoscyamus. Tn doses above three grains the 
pulvis Jacobi is sometimes rejected from the stomach. An ex- 
cessive drain by the skin is not at all to be desired in these cases; 
we must remember that there is another channel through which 
watery secretion is carried off, and in which it forms the medium 
for eliminating noxious and irritating materials, such as urea, uric 
acid, and various chlorides, sulphates, and phosphates, besides 
other ingredients. All these effete materials, which have to pass 
through the kidney, are increased in quantity in fever, and if the 
fluid requisite for their solution or suspension be drained off 
through other channels, as the skin, their complete elimination 
may not be effected, and their retention in the system may be the 
cause of secondary mischief. I do not feel satisfied that the ex- 
cessive cutaneous sweating, and the partial or complete suppres- 
sion of urine, which we observe in certain cases of fever, do not 
stand in some relation of cause and effect to each other. I can only 
say that I have seen total suppression of urine supervene in cases 
in which there has been excessive and continuous cutaneous action. 
We must not forget that there is often a very considerable drain 
of watery vapor from the system through the lungs in fever; thus 
we may note that of two cases, one being fever, and the other 
some apyrexial disease, lying side by side in hospital, the quick- 
ened respiratory movements of the one (a fever case) are attended 
by visible moisture issuing from the mouth at each expiration ; 
while, under precisely the same conditions of temperature, the 
breath of the patient in the next bed does not exhibit perceptibly 
moisture ; a glass or polished metallic surface held near the mouth 
will show the same effect more strikingly. 



DIURETICS IN FEVER. 81 

Purgatives in Fever. 

"We have already indicated our opinion of the mischief so often 
done by the abuse of purgatives at the outset of fevers. The 
symptoms referable to the abdomen and lower extremities, 
which we have already noticed, call for the use of purgatives in 
moderation, but it is idle to think of effecting a cure of the fever 
by drenching the patient with purgatives. Mild saline aperients, 
when judiciously employed, have a salutary and cooling effect ; 
the sulphates of potash, soda, and magnesia, may be used for this 
purpose, in drachm or two drachm doses ; the tartrate of potash 
may be employed with like effect in half drachm or drachm doses ; 
these salts, however, will require the addition of a carminative to 
correct their tendency to gripe the patient. In cases where a 
bilious congestion is present, a mercurial purgative will be of 
use; the calomel bolus (five grains to the dose), or the combina- 
tion of blue pill and colocynth (five grains of each), will stimulate 
the liver sufficiently. Drastic mercurial purgation is to be care- 
fully avoided ; it lowers the system, and is not free from the dan- 
ger of producing enteric irritation or perhaps inflammation ; the 
latter I have more than once seen. 

Diuretics in Fever. 

If we give a separate heading to this class of remedies, it is 
only for the purpose of strongly deprecating their use, unless 
under very rare and exceptional circumstances. If the urine be 
scanty at the outset, dark red, and loaded with deposit subse- 
quently, its specific gravity being sensibly increased, and the 
urinous odor very strong, we know that these symptoms, instead 
of indicating derangement of structure or function in the kidney, 
prove that this part of the eliminative apparatus is doing increased 
duty. The neutral salts, given as before indicated, furnish suffi- 
cient stimulus, where any such is required. Deranged action of 
the kidney to any serious extent is of the very rarest occurrence 
in synochal fever. For such complications as may possibly occur, 
including suppression of the urine and its treatment, we refer 
the reader to a subsequent section, in which the subject is treated 
in connection with remittent fever. 



82 SYNOCHA. 



General Management of a Case of Synocha. 

Thirst is a symptom often troublesome in these cases ; the lips 
and tongue are parched, and the patient greedily swallows, if 
allowed, unlimited quantities of fluids. Drinks of various kinds, 
and fruits, are supplied as the cravings of the patient demand, 
and yet he drinks and sucks fruits with still unsatisfied thirst. 
Much mischief is often thus induced ; the stomach becomes over- 
loaded, and weakness and dilatation of this organ, with flatulent 
irritation, and sometimes tympanitis, with subsequent tormina, 
gripes, and diarrhoea, are entailed on the patient by the injudicious 
kindness of friends. The practical rule is to allow drink only in 
moderation, and that of the simplest kind ; cold spring water or 
iced water may be allowed in small quantity, the patient being 
directed to retain the fluid in the mouth and fauces as long as 
possible. There seems to be no ground for the apprehension 
commonly entertained with respect to cold water, if only it be 
drank in moderation, and the patient be prevented from drench- 
ing his stomach with it. Effervescing mixtures, soda water, seltzer 
water, Carara water, and others of the same class, may be used 
with good effect if given in moderation. 

As a specific against the cravings of thirst, camphor mixture 
is lauded by some practitioners, and I have myself found it useful. 
It is not necessary to specify further the various drinks which the 
ingenuity of nurses and friends supplies to the sick-room ; we 
must allow some scope for the officious kindness of those who 
minister to the wants of a sick parent, child, or friend. What 
we must be guided by is moderation in all things ; in many cases, 
no doubt, it will be found necessary for us to intervene with all 
the authority of our art, and leave not the smallest discretion, as 
to the use of food, drink, or medicine, in the hands of troublesome 
or fussy people. 

In all cases secure full control over^ the general arrangements 
of the sick-room: see that it is well ventilated, yet free from 
draughts ; insure order, quiet, and silence, and permit no more 
than two persons to remain with the patient at a time. 

In regard to food, bear in mind that it is not our object either 
to starve the patient, or, again, to give him nutriment in kind or 
quantity which he cannot digest. It is well for the sake of regu- 



GENERAL MANAGEMENT. 83 

larity, to observe for the sick man the same order of his meals, and 
the same alternation of night and day as when he was in health. 
Let the food be light, mild, and well blended ; if a little tea is 
wished for in the morning, there is no reason to withhold it; arrow- 
root, sago, panada, light flummery, or even jelly may be allowed 
between twelve and three o'clock; light drinks may be given late 
in the day ; but, as a general rule, let the patient have no solids 
after sunset. There is often a decided though slight tendency to 
exacerbation of the symptoms at the close of the day ; the pulse 
gets up a few beats, the skin becomes more hot and dry, and there 
is restless excitement, with a sense of heat and feverish oppres- 
sion. This is especially the case when the patient has been 
worried by the well-meant but ill-timed kindness of friends, the 
excitement of conversation, and the strain on the nervous system, 
consequent on seeing and conversing with a succession of visitors. 
It is surprising what a state of feverish excitement, with tossing 
sleeplessness and miserable unrefreshing nights, will be entailed on 
a patient who has been allowed to pass the day (agreeably enough 
for the time) in the distraction of seeing a round of anxious but 
inconsiderate friends. "A quiet day gives a quiet night." Eelapse 
is not infrequently caused by the injurious effects of mental ex- 
ertion disproportionate to the patient's state in fever. 



84: VARIETIES OF SYNOCHAL FEVEK. 



CHAPTER V. 

VARIETIES OF SYNOCHAL FEVER. 

There is much difficulty in reducing to a common scale the 
various fevers recognized from time to time under the head of 
Synocha. Grant, one of the ablest writers of the last century, 
considers the febris pituitosa, the synochus non putris, the febris 
humoralis, the epialos, and the slow nervous fever of Huxham, to 
be the same disease. The synochal fever of his own day Grant 
describes as setting in some time in March, and lasting for a con- 
siderable period, commonly till after the summer solstice. He 
recognized as different varieties of this fever, the synochus sim- 
plex, which lasted only four, or at most seven days, and the febris 
typhodes, assodes, lyngodes, phricodes, pituitosa, and lypinea, all 
.so called from their several characteristic symptoms. In refer- 
ence to the treatment adopted by the physicians of that day, he 
says — "They followed nature and assisted her;" but he cites the 
somewhat caustic observation of an ancient physician, who re- 
marked, " that a new treatment often turned an old fever into a 
new one." Grant further makes the remark, that in 1769, till 
the warm weather set in, in the beginning of March, he did not 
hear of any slow nervous fevers; he considered the fever, of which 
he then saw several cases, as having the same symptoms and 
course as the hemitritaWand trytseophyse of the ancients, and as 
the flbris hungarica, gastrica, cholerica, mesenterica, febricula, and 
lenta of the moderns, but as different from the bilious fever. 

It is a by no means promising task, and is one which we have 
neither time nor inclination to follow up at present, to attempt to 
bring into order under one category the various forms of fever 
described by the older authors. Much of the labors of the older 
schools are devoid of practical application at our hands, to the 
elucidation of the nature of the several fevers of which they treat, 



VARIETIES OF SYNOCHAL FEVER. 85 

from the absence of any strict pathological data whereby we 
might judge of their identity or non-identity with the correspond- 
ing forms of disease which now prevail. 

We can hardly fail, however, to recognize as true to nature, 
even when judged by our experience of the present day, three 
principal groups of febrile action prominently delineated by all 
the great writers of past times. I allude to the classes of the 
inflammatory, the nervous, and the putrid fevers, which stand 
out in relief in the writings of the authors of the sixteenth, 
seventeenth, and eighteenth centuries. The first variety com- 
prises the simple continued fevers of our own day, which occa- 
sionally still, though perhaps in all probability not as frequently 
as in former times, exhibit high pyrexial reaction, bounding pulse, 
and delirium, and other of the so-called " inflammatory" symp- 
toms. The nervous fevers, I believe it is highly probable, com- 
prised at all times before the development of modern pathological 
anatomy (and even since then, in too many instances, as I have 
myself reason to know), febrile affections of essentially opposite 
character, and of occasionally totally different pathological nature, 
in which, however, there was the one common feature of nervous 
debility alternating with nervous excitement, but in which there 
was a total absence of the putrid phenomena, so-called. 

This group comprised the slow nervous fever of Huxham, and, 
in all probability, the gastric fever and the febris lenta, and all 
those febrile diseases to which the term synochus non-putris was 
applied. 

As an example of the difficulty of defining fevers accurately 
without the aid to be derived from morbid anatomy, I may men- 
tion the instance of a case of typhoid fever which exhibited the 
most profound enteric lesions, and which during life, from the 
absence or latency of special abdominal symptoms, was regarded 
as an example of " nervous fever" by practitioners of no incon- 
siderable experience. 

The putrid group of fevers of the old school comprises, of 
course, the true typhus, spotted, or gaol fever, or, as it is other- 
wise known, the maculated, petechial, Irish, and the camp or 
hospital fever. 

Synocha, as we have defined it, will be found to comprise the 
majority of the ordinary non-typhus fever cases which present 
themselves to the notice of the physician in the present day. We 



86 VARIETIES OF SYNOCHAL FEVER. 

have, it will be seen, given to the term a somewhat more large 
and liberal interpretation than that assigned to it in the nosology 
of the older schools. It will be found to include the seven-day 
fever on the one hand, and, on the other, those fevers which run 
on to the fourteenth or twenty-first day, terminating either by 
crisis, or by the gradual subsidence of the pyrexial action, elimi- 
nation of effete materials taking place gradually through various 
emunctory channels. The shorter fevers terminating by crisis on 
the seventh day, or thereabouts, and marked by high pyrexial 
action, with intense heat of skin, full and bounding pulse, and 
often attended with much nervous and cerebral excitement, cor- 
respond to the xavais of the Greeks, and the inflammatory fever 
of the later schools. This class of fevers is not very commonly 
met with in the present day. 

The fevers of longer duration, running on to fourteen or twenty- 
one days, without eruption of any kind upon the skin, and unat- 
tended by the prostration of typhus ; on the one hand, or the 
enteric complications of typhoid on the other, constitute the 
simple continued fever of modern times, and the well-known 
" F. c. c." or febris continua communis of the official army re- 
turns. 

Both the "short" and "long" fevers of this class differ in some 
important respects from the fevers we shall have subsequently to 
consider. 

(a.) They are rarely found to be endemic or epidemic; they 
occur for the most part sporadically, and are due to such causes 
as over-exertion and fatigue, excess in food or drink, sudden ex- 
posure to excessive cold or heat, and similar agencies which affect 
individuals more often than masses of men. 

(b.) Though not devoid of danger, they are not commonly fatal, 
and the proportion of mortality which they present on the whole 
is very small. 

(c.) They seldom if ever leave a profound impression of any 
kind upon the system, and an attack of this kind of fever confers 
no immunity whatever against attacks of a similar kind, at sub- 
sequent periods of the patient's life. 

Epidemics of Synocha have been recorded by some writers, 
but for the reasons already furnished, and in the absence of data 
derived from pathological anatomy, we are at a loss to know 



DIFFERENT TYPES OF FEVER IN DIFFERENT RACES. 87 

whether to accept or reject the statements transmitted to us as to 
the exact nature of the fever which prevailed in these invasions. 

It is important to note that the synochal types of fever appear 
to have certainly become less frequent in these countries of late 
years than they must have been at one period, if we accept the 
accounts given us by former writers. And on this head, I for 
one am not prepared to go to the length of scepticism insisted 
on by some uosologists of the present day. We can no more 
argue to the rarity or non-occurrence of the inflammatory fevers 
in these countries in a former day, from their infrequency in 
modern times, than we could argue to the non-occurrence of the 
sweating or miliary fever, or " English sickness," as it was called, 
from the extreme rarity of this affection amongst our present 
population. And yet though the sweating fever is all but 
banished from these countries in our day, its existence in former 
times as an almost permanent endemic, and as a largely fatal 
epidemic, is a historic fact placed beyond all possibility of con- 
troversy. 

I have myself formed the notion, but I in no way insist on it 
as a well-grounded hypothesis, that the sthenic or synochal types 
of fever are in the present day, and perhaps have always been, 
most remarkably developed amongst the graminivorous and 
herbivorous races of men, while the putrid or typhus types of 
febrile action more readily develop themselves in the races 
amongst which animal food constitutes a large part of their 
ordinary aliment. 

The general constitution of races, and, on a smaller scale, of 
masses of man banded together as armies, seems in no small degree 
to influence the characters of the febrile affections developed 
amongst them even when the climatic conditions are not dis- 
similar. As illustrative of this class of observations, it may be 
mentioned, that amongst the armies engaged in the late Russian 
war, somewhat dissimilar types of febrile disease became developed. 
Thus, in the Sardinian army encamped in the Crimea, a sthenic 
type of fever partaking of the characters of synocha, was preva- 
lent, in which the pyrexial action was so high, that the very 
intelligent medical officers attached to the Sardinian forces judged 
it necessary to bleed freely from the arm. 

In the English, French, and I believe ultimately in the Rus- 
sian services, putrid types of fever prevailed, in which stimulants 



55 stx::hvs, 

were urgently called for, and freely employed. Amongst the 
Turkish troops, sweating fever, with the characteristic foul ema- 
nations from the sutaneoiis surface, was exhibited to a consider- 
able extent. 

Sach general observations as the foregoing must not however 
be pushed too far. It is all but impossible to get the problem 
:: stand on all fours in such instances as those sited as we have 
always to make allowances for differences in the age and cam- 
paigning experience and maturity of the troops furnishing the 
subjects :: somparison, and for the Effects :: iiet, exposure to 
hardships, and the iength of time they have served through the 
?a:gn. which is made tae means :: testing their :■: reparative 
patholgical tendencies. 

It is nevertheless highly probable that we have ye: :: staay. as 
an independent branch of medical science, what we m y lesignate 
as Comparative PathoIo«ry. 



SYNC CHU5. 

The next variety of fever we should have t: ::nsifer is that 
known as sync thr.s. or the mixed or net"r; is fever. This, how- 
ever, is not by any mentis a ^rii iehnei variety :: pyre 
action, and some anthers refuse altogether to assign it any place 
in the nosological scale. It has been described as a fever com- 
inencing with the chara iters of synocha, and ending with those 
of typhus : but this is completely to deprive it of all specific 
character, for a fever thai terminates as typhus is to all intents 
ana rnrpcses typhus fever. 

I am myself not by any means satisfied that we are warranted 
in rejecting synochns, and I believe it might be made a conveni- 
ent head under which to rank the so-called "nervous fevers/' and 
pre be ibly also the i: perniti ; as fevers," with some other varieties 
of pyrexia! action, the nosological position of which is as yet 
unsettled Bnl as this whole subject still rests on very debatable 
ground. I shall refer to another time the consi ieral ion : f synoebos 
and its varieties. 

Amongst the minor types of continued fever we may notice 
the affections known as febricula and ephemera, and also the mild 
form of febrile action called into existence bv the effects :■£ the 



RELAPSING FEVER. 89 

inhalation of such odorous particles as those emanating from 
newly mown hay, and hence designated " hay fever." 

Ephemera and febricula are mild types of pyrexial action, 
scarcely requiring medical interference, and which run their 
course within twelve to twenty-four hours, but are occasionally 
of longer duration. The " hay fever" is often induced from the 
cause above assigned in persons of delicate temperament, in the 
early summer time. It may last two, three, or more days, and I 
have known it to assume the form of a relapsing fever. 

RELAPSING FEVER. 

This form of fever is characterized by the occurrence of a py- 
rexial attack, which terminates usually by crisis more or less well 
marked on or about the seventh day. Subsequent to this the 
patient convalesces, but after an interval which is very variable, 
and may be extended from two or three to seven or eight days, 
he undergoes a second attack, which is ushered in by rigors and 
the usual train of pyrexial phenomena, and he is again prostrated 
by febrile disease, which may last for seven or eight days, to 
terminate as before by crisis. In some instances a second relapse 
takes place, and in extreme cases a fourth attack has been known 
to supervene. 

The relapsing fever is of importance from its tendency to epi- 
demic invasion. Epidemics of this form of fever are recorded 
during the last century, and since 1817 it has been known to 
occur on several occasions in Ireland and Scotland, as an epidemic 
visitation of considerable magnitude, but not of an extensively 
fatal character. In England this affection is less common. On 
the continent of Europe and in America, it is a disease not ex- 
tensively met with. 

While I admit the frequent occurrence of relapsing fever in 
Ireland, I must be allowed to record here my protest against the 
statements recently circulated on very insufficient data, that re- 
lapsing fever constituted the large majority of the cases of the 
famine fevers of Ireland. The contrary of this I believe to be 
the case ; and having had large and extended experience in the 
last great famine fever visitations of Ireland in 1846, 1847, 1848, 
I can certify that the maculated typhus was the disease which 



90 RELAPSING FEVER. 

chiefly prevailed ; while the relapsing fever presented itself only 
at the close of the great typhus visitation. To cite no other 
proof: we may note that the deaths from fever in Ireland in the 
ten-year period, 1841 — 1851, amounted, as already stated, to over 
200,000, a mortality which it is impossible to account for on the 
supposition that the prevailing epidemic was one of relapsing 
fever, which is certainly by no means a very formidable or fatal 
disease. 

Amongst the premonitory symptoms of relapsing fever, we 
may mention nausea, pains in the back and limbs, severe head- 
ache, and not unfrequently greenish or yellowish bilious vomiting. 
Pyrexial action is speedily developed, and reaches a high degree 
of tension ; the pulse is frequent — 120 to 130 or upwards, and 
occasionally bounding ; the throbbing in the temples is a source 
of much suffering; and the gastric symptoms are often severe; 
the urine is high colored and scanty. There is also much ten- 
dency to engorgements of the liver and spleen. Jaundice to a 
slight extent is an occasional, but not constant symptom. The 
diagnosis of this fever is not easily made during the primary 
attack in isolated cases. In periods when the affection prevails 
epidemically, the suddenness of the invasion and the rapidity with 
which the febrile symptoms reach a height, with the persistent 
character of the gastric symptoms, and greenish or yellowish 
vomiting, will readily lead us to form a correct opinion as to the 
nature of the case before us. These symptoms are, however, not 
always of so well denned a character. 

The character and duration of the first relapse, and of the 
second relapse when such occurs, are not strictly determined by 
those of the first attack. In many instances the fever of relapse 
is of a much graver character than the primary disease, and 
occasionally death occurs in this period, a collapsed and algid 
condition supervening in an unexpected manner, and sometimes 
with great suddenness. 

Convulsions prove fatal in certain cases of relapsing fever. 
Delirium has been known to occur during convalescence in a very 
sudden manner ; but from my own experience of the disease in 
this country (Ireland) and in the east, I am disposed to regard 
these occurrences as of great rarity. 

During convalescence from relapsing fever, a singular cardiac 



CHARACTERS OF RELAPSING FEVER. 91 

murmur has been noticed. 1 It was a soft systolic sound, propa- 
gated up the aorta, heard loudest in the recumbent position, in 
most instances becoming all but imperceptible when the patient 
assumed the erect posture, finally disappearing as convalescence 
progressed, and. manifestly not of organic nature. 

The following observations, based on researches conducted in 
the Crimea, are of interest, as showing the occasional connection 
of relapsing fever with the typhoid types of disease. 

During the summer months of 1855, this form of disease was 
pretty common amongst the British troops in the Crimea. The 
primary attack commenced with or without diarrhoea ; often with 
pretty sharp symptoms, so that by the second or third day the 
febrile state was very well established. Headache was very 
general, and often severe; the pulse was full and quick, and 
" calor mordax" of the skin was constant. The tongue was loaded, 
some gastric irritation and also diarrhoea was often present 
through the course of the disease. 

Sometimes, so early as the fifth or sixth day, these symptoms 
had entirely subsided, a more or less perfect crisis, usually by 
sweating, taking place. The patient felt well, was soon able to 
get up, and in a few days convalescence was apparently complete ; 
so much so, in some instances, that the men returned to duty, 
often at their own request. But, after a variable period, a new 
invasion of febrile symptoms took place, occasionally with in- 
creased severity. The patient again sought admission into hos- 
pital, and soon presented a much more fully developed febrile 
state than in the first attack. 

Two, three, four, or more days, sometimes a much longer 
period, intervened between the first and second attacks. No 
definite period of intermission was, however, observed. In some 
cases the patients had convalesced for but a day or two, when the 
second attack began to show itself. In others, as I have said, 
the intermission was such that they were able to return to their 
duty. It did not appear that there was anything definite as to 
the times of occurrence of remission and relapse, and we always 
failed to notice anything that would warrant the idea of actual 
periodicity throughout the course of these fevers. 

1 Observations of Drs. Heslop and Lyons in the Meath Hospital, Dublin, 

1847-8. 



92 RELAPSING FEVER. 

The type of fever which was established in the relapse varied 
very much in different cases, and there did not seem to be any 
constancy, either in the characters or in the duration of this 
second fever. 

In general the fever of relapse assumed a sufficiently grave 
type. Pyrexia, expressed by more or less nervous excitement, 
high pulse, hot skin, loaded tongue, and often diarrhoea, became 
well established ; and in some instances the disease lasted for a 
full period of twenty-one days ; in rare cases still longer. I have, 
however, known very many cases in which the second fever was 
of a slight character and of brief duration, terminating in from 
seven to ten days ; but the febrile state never seemed to be thus 
completely thrown off, and in cases of this kind we have seen a 
third, and even a fourth relapse. 

Perhaps the most remarkable feature of this class of fevers was 
the almost total absence of any constant or very definite charac- 
ters. Neither in the pyrexial phenomena, the duration, or the 
modes of termination of the first attack, was there anything of a 
very fixed nature. The short primary attack not infrequently 
terminated with a pretty well-marked crisis by sweating. But 
in the secondary attacks it was exceptional to find any approach 
to a definite crisis of any kind. The period of intermission was 
inconstant, varying from two to many days. The characters of 
the second, or, when it occurred, of the third attack had, in many 
instances, no necessary relation or similarity whatever to those of 
the first. In many instances they differed most widely, so much 
so that it seems fair to assume that, in some cases at least, the 
first disease stood only in the relation of an accidental, not a cog- 
nate antecedent to the second. 

It will be well to observe here, that during a period embracing 
the months of July and August (1855), it was a very common 
character of the fevers which prevailed, that in the great majority 
of instances, a patient, instead of being attacked with one defined 
fever, progressing in a uniform way from its invasion to its final 
issue, exhibited usually one short first febrile state, from which he 
convalesced more or less completely, but was soon again the vic- 
tim of a second, perhaps graver attack. 

Within the period here assigned, this mode of invasion of febrile 
disease was the general one ; before and after it, unity of attack 
was the rule. 



TREATMENT OF RELAPSING FEVERS. 93 

Of the fever occurring within this order of association, be it 
accidental or otherwise, within the time above specified, I have 
known both the typhus and typhoid types to have been well 
exemplified. In some fatal cases, the characteristic enteric 
lesions of the typhoid fever were seen to be fully developed. 
In a clinical point of view, as a possible antecedent to fatal forms 
of disease, this relation of the short primary fever deserves to be 
borne in mind. 

As to the other clinical characters of the relapsing variety of 
fevers just noted, they differed in no important respect from those 
elsewhere presented in similar forms of disease. No fatal cases 
came under our observation in the Crimea. 



Treatment of Relapsing Fever. 

In the primary attack, when the pyrexial excitement is 'high, 
depletory measures may be occasionally called for ; but we must 
bear in mind that the patient has in all probability more than one 
febrile attack to go through, and we must husband his strength. 
This precaution is especially necessary when, from the epidemic 
constitution of the time or of the class of patients we have to deal 
with, there is any reason to anticipate the possibility of the re- 
lapse fever assuming either a typhous or a typhoid type. If 
constipation be present in the first attack, a moderate use of mild 
purgatives is indicated ; and when biliary engorgement is present, 
the mercurial bolus or blue pill and colocynth will be employed 
with good effect. 

In those cases in which the head symptoms preponderate, 
leeches to the temples and cold lotions, or, in extreme cases, 
shaving the head and the application of the ice-cap will be bene- 
ficial. 

When gastric derangement with excessive bilious vomiting 
occurs, we may suspect that the primary seat of mischief is in the 
liver. Our views in this respect will be confirmed if we find that 
there are heat, dull pain on pressure, and an enlarged circle of 
hepatic dulness. Cupping or leeching over the liver will be 
useful in such instances at the outset, and subsequently we may 
employ counter-irritation in the same situation. Epigastric pain, 
heat, and tenderness, will be relieved by the application of a 
blister or a mustard poultice; while the internal use of iced 



M RELAPSING FEVER. 

drinks, hydrocyanic acid, and occasionally morphia in small 
doses, will often be found serviceable. 

It will not be necessary to dilate more fully on those principles 
of treatment applicable to the management of the ordinary py- 
rexial symptoms of the relapsing fever, and which are common 
to it and the synochal types of febrile disease. These we have 
already discussed at sufficient length. 

In the interval which elapses between the primary febrile 
attack and the relapse, and during which (so fallacious are the 
symptoms of convalescence) the patient often appears to be 
steadily progressing to the complete recovery of his health, the 
utmost caution is requisite on the part of the physician. 

The patient should be warned against all excess in food, drink, 
or exercise, and in the case of bodies of men in the public service, 
the patients should not be allowed to return to active duty till 
after the lapse of an interval sufficiently long to embrace the 
period of relapse, if such is about to take place. 

The constitution of patients who have undergone relapsing 
fever, with the two or three successive attacks of febrile disease 
which it entails, is often much impaired for the time. There is 
general relaxation with muscular weakness, loss of tone in the 
vessels, a worn and sallow appearance, and occasionally a ten- 
dency to slight anasarcous swellings in the extremities. It is 
also possible that in this low state of the system latent dyscrasic 
types of disease may be called into activity, as in the instance of 
individuals predisposed to the tuberculous diathesis. 

A course of tonics and chalybeates, a generous diet, and a 
liberal but not excessive use of wine, with change of air and 
scene, are the means which most readily enable the constitution 
to rally from this state of temporary depression. If not assisted 
by such means, there is danger that the patients may sink from 
lingering disease, 



TYPHOUS FEVERS. 95 



CHAPTER VI. 

TYPHOUS FEVERS. 

The term Typhous is derived from the Greek word tv$os, 
stupor, and has been used to designate a class of fevers in which 
a low prostrate condition of the system is present, marked espe- 
cially by a torpid state of the intellectual faculties, and of the 
nervous energies in general. Under this head are comprised 
various fevers, known to authors as putrid and malignant fevers, 
the jail and camp fevers, the febris bellica, and the spotted or 
petechial, maculated or Irish typhus fever, as well as the typhoid 
or enteric fever, or, as it is now sometimes called, the pythogenic 
fever. 

Fevers of the typhous type present themselves sporadically, 
endemically, and epidemically. 

The first epidemics of typhus of which we have reliable ac- 
counts are those which occurred in Italy at the commencement 
of the sixteenth century, and which were described by Fracastor 
of Verona. 

The geographical limits of true typhus may be stated to be, in 
Europe, from 40° to 60° K. lat., and on the American continent 
between 30° and 50° 1ST. lat. ; it is said to exist in no place where 
the mean annual temperature rises above 62° Fahr. or falls below 
40°. Dr. Morehead asserts that typhus is unknown in India ; 
and Dr. Alex. Webb is the only author, so far as I am aware T 
who has recorded its occurrence in the Indian empire ; he notices 
two cases as having occurred at Simlah. 

But it is within the European and American limits above 
assigned that typhus is found to occur as a really formidable 
scourge of the human race. Some idea of the extent to which 
it prevails may be formed from the results obtained by the Census 
Commissioners of Ireland, which show that in the ten-year period 



\)b TYPHUS. 

between 1841 and 1851, over 200,000 deaths took place from 
fever, and of those deaths the greater number were undoubtedly 
due to the spotted or petechial typhus. 

All the fevers met with in the typhus category present certain 
striking features in common, namely, early prostration if not 
collapse of the system, a peculiar dusky appearance of the skin, 
a semi-livid state of the countenance, a dull, stupid, and torpid 
condition of the intellectual and general nervous energies ; the 
patient being in a state of semi-consciousness, from which, how- 
ever, he is easily roused, answers questions coherently, but 
relapses immediately into a state of apparent torpor and uncon- 
sciousness. The vascular reaction is generally feeble, and in 
extreme cases there is a tendency to death and gangrene in the 
peripheral parts, from failure of the circulation. 

The combination of symptoms we have here described will be 
found to characterize certain diseased states, which differ much 
in essential details and in their duration and course, and the 
particular organs implicated by them. It may be advantageous 
to employ a term which would comprehend the several diseased 
processes here alluded to ; and the term Typhosis may be intro- 
duced to embrace the very well-marked groups of morbid phe- 
nomena above described. 

The following morbid states may be recognized under the 
common head of " Typhosis." 

TYPHOSIS. 

Various Forms of . 

I. The typhus fever proper, which comprises the spotted, pete- 
chial, malignant, and gaol or camp fever, and the Irish typhus, 
par excellence. 

II. The typhoid or enteric fever, or dothionenterite, otherwise 
known as the pythogenic, and sometimes as the French or Con- 
tinental fever. 

III. A state of the system in which, independently of the 
before-mentioned essential fevers, the pyrexial action which 
attends local diseases, such as bronchitis, pneumonia, and occa- 
sionally hepatitis, assumes all the characteristics of the low 
typhoid condition, with tendency to early sinking, collapse, and 
fatal issue. 



EARLY PROSTRATION IN TYPHUS. 97 

IV. A state which supervenes upon cholera, and which presents 
a pyrexial reaction, having marked typhoid characters of the 
kind above detailed. 

V. A condition of the system which follows upon severe inju- 
ries, wounds, or surgical operations, and upon such diseased pro- 
cesses as erysipelas, phlebitis, and purulent absorption. This is 
the state so often preluding a fatal issue, which is implied when 
we hear it said that the patient has sunk into a low typhoid con- 
dition. 

It would be an interesting question in speculative pathology 
to investigate the mutual relations, and probably common nature, 
of several of the great morbid processes just enumerated, but 
such inquiries are beyond our present limits. It is remarkable 
that, while two of them at least present the features of inde- 
pendent, essential fevers, the pyrexial reaction in the other three 
states seems to take its origin from localized disease in the first 
instance. 

It is not our intention here to enter at length into the vexed 
question of the identity or non-identity of the typhus and typhoid 
fevers, so called. "We shall recognize a practical, clinical differ- 
ence in the course, duration, symptoms, and secondary lesions of 
the two morbid processes. It is indeed not improbable, that 
while they are to be regarded as branches of the same stock, they 
recognize a different exciting cause. The natural history of the 
two diseases differs likewise in many essential respects. The 
spotted typhus, for instance, it is well known, is historically 
associated, in Ireland and elsewhere, with great famine periods, 
and a depressed and impoverished state of the population. The 
typhoid or enteric fever, on the other hand, is not largely called 
into existence by these agencies ; but it has been shown to be 
connected with such causes as imperfect ventilation, impure water 
supply, bad sewerage, and the foul emanations of animal and 
vegetable refuse and human ordure. 

The Typhus or spotted fever presents the following clinical 
characters. The invasion of the disease is generally insidious, 
though we meet with occasional instances of sudden accession of 
the symptoms of prostration, if not collapse. There is rarely 
any period of well-marked incubation; the rigors, pains in the 
head and back, and lassitude of the extremities, with failure of 
the nervous and muscular energies, come on insidiously, and the 
7 



98 TYPHUS. 

patient has no idea of the gravity of the disease which threatens 
him, and struggles on against it with a vain effort to shake it off. 
It constantly happens, in cases amongst the lower classes of so- 
ciety in Ireland, that a patient struggles on against the depressing 
influences of the disease for days together, and pursues his ordi- 
nary avocations as best he can; in the end he finds himself over- 
come by the influence of his malady, and seeks advice at the 
nearest hospital or dispensary. The experienced eye of the phy- 
sician detects at a glance that the fell typhus is upon the victim; 
he is admitted into hospital, and in twelve hours it would be 
almost impossible to recognize in the collapsed, torpid, and semi- 
conscious patient lying prostrate before us, the man who, through 
failing strength, had desisted from active bodily labor but half a 
day previously. We have in this class of cases a remarkable 
evidence of the moral influence exercised upon disease, under the 
pressure of necessity, which drives the patient to the exertion of 
almost the last muscular effort which is left him. When the 
necessity for exertion has passed, the patient succumbs rapidly 
and profoundly under the depressing typhus influences; this is a 
fact which must be familiar to all Irish practitioners, and is one 
which is not without an important and practical bearing on the 
ultimate course of such cases. Thus we find that patients who, 
in the weakened state of their system induced by the early stages 
of typhus, largely expend nervous and muscular force, have to 
pay the penalty ultimately, by undergoing very low and pros- 
trating forms of the disease. Great sinking and tendency to early 
fatal issue ensue in many of these cases. The practical indica- 
tion furnished by such observations is, that in all cases of sus- 
pected typhus, we should take the utmost care to husband the 
patient's strength from the outset. For these, and other if pos- 
sible more urgent reasons, it is highly desirable that, in a sus- 
pected case of typhus, we shall be able to make our diagnosis at 
as early a period as possible. And yet, no class of case will 
progress for so many days, without its presenting a single sign 
by which it would be possible to predicate that the disease is 
absolutely typhus, or about to be such ; till, in fact, the appear- 
ance of the characteristic eruption, which it is no uncommon 
thing to find delayed until the seventh or eighth day, we are not 
in a position to state upon perfectly positive evidence that the 
case is one of typhus. How much of mischief, and how much of 



GENERAL PHYSIOGNOMY OF TYPHUS. 99 

ultimate peril to the safety of our patient, may not be entailed 
by the measures adopted by the physician within this period ! 
Seven days are a long period to wait expectant by the bedside of 
disease, uncertain what counsel to hold, what measures to use, 
what prognostics to indulge. Seven days seem a long period to 
wait in inaction, when no clear course is open to us. In seven 
days, many a form of fever will be brought to a final and favor- 
able issue. And yet, in typhus fever it will often require seven 
days of marching and counter-marching before we know what 
the enemy is which we have to encounter, and before we know 
the ground upon which we have to give him battle. In these 
seven days, what patience, skill, fortitude, and moral courage are 
not requisite on the part of the physician, to enable him to re- 
frain from meddlesome and injurious interference with his case, 
pressed as he is from within, by a sense of responsibility, and 
from without, by the anxious expectations and often urgent soli- 
citude of friends, who think that it is a doctor's business to be 
always doing something for the patients under his charge — now 
bleeding, now sweating, now purging, and anon counter-irritating, 
with a perpetual recurrence of pills, potions, and external appli- 
cations, and a never-ending round of drinks, medicines, stimu- 
lants, and such like measures! 

It might be said without exaggeration, that more cases of 
typhus are lost and won by what is done or left undone within 
the first seven days, than by almost anything which may subse- 
quently happen in the progress of the disease. 

Though devoid of characters of an absolutely specific kind 
until the lapse of the first five or seven days, typhus fever com- 
monly presents, after the first twenty-four or forty-eight hours, a 
marked physiognomy, and certain general features, by which the 
well-experienced eye may be safely guided to a diagnosis in the 
great majority of instances. 

We shall now take up the consideration of those general fea- 
tures which characterize a case of typhus fever. 

General Physiognomy of Typhus Fever. 

We may group the phenomena presented under this head in 
the following order: — 

(a.) A state of general prostration of the patient is noticeable 
from the outset; it is not uncommon to find this developed so 



100 TYPHUS. 

early as the third or fourth day. And when a patient bears up 
against the impression of the disease to the fifth, sixth, or seventh 
day, prostration supervenes in the end, with a suddenness and 
completeness for which we find no parallel in any other form of 
disease. This is the case in those instances in which a patient, 
having toiled on at manual labor till suppose the fifth day, is able 
to walk to hospital, and to give some account of his symptoms, 
and yet is in twelve hours subsequently in a state of the most 
profound typhoid collapse, as already explained. If we compare 
for an instant the features of a case of synochal fever and one of 
typhus, we shall be struck with the following points of contrast. 
In the one (that of synocha), the patient presents great vascular 
excitement, flushed face, a lustrous and perhaps fierce-looking 
expression of the eyes, great restlessness, much heat of skin, 
strong and perhaps bounding pulse, and a state of the system 
which may be generally expressed as being much above par. In 
typhus, on the contrary, the prostration we are describing, and 
the other symptoms about to be noticed, are commonly well 
shown by the fifth or sixth day. 

(5.) A flaccid state of the limbs, with great muscular debility, 
and dorsal decubitus, are, when early developed, very character- 
istic of typhus. 

The way in which the patient lies in bed in typhus is peculiar; 
the head is low, and the patient's body slips down in the bed, till 
the limbs, trunk, and head, by the force of gravity, are nearly 
horizontal. 

(c.) A peculiar state of semi-consciousness is early developed 
in typhus; the patient lies listlessly on his back, taking no heed 
of what is passing around him ; the eyes are half closed, or, if 
open, have a glazed, dull, and vacant expression. However, if 
shaken, spoken to loudly, or otherwise roused, it is often found 
that the faculties are still perfect; when questioned, he answers 
coherently, and the intellect is found clear and the memory 
undisturbed. He relapses immediately into the same unconscious 
state, when we cease to attract his attention or to question him. 

The passive state here described is in marked contrast with 
that found in the synochal fevers, though, of course, typhus 
presents occasionally complications, with delirium, muttering, 
restlessness, and other symptoms which indicate vascular and 
nervous excitement. 



SPECIAL CHARACTERS OF TYPHUS. 101 

(d.) Typhus cases exhibit a peculiar dusky, somewhat bluish, 
and rather dirty-looking appearauce of the entire cutaneous sur- 
face ; this discoloration, of a bluish or somewhat livid tint, is due 
partly to a sort of venous stagnation in the capillaries of the skin, 
and partly to an impure and ill-aerated state of the blood. 

(e.) The appearance of the face is highly characteristic, and 
often of itself announces the disease the patient is laboring under. 
It partakes of the general dusky tint of the rest of the surface, 
but there is a peculiar reddish brown upon the cheeks at the 
malar prominences. The eye is very peculiar, though its charac- 
ters vary a good deal; it is suffused, half open, the conjunctiva 
slightly congested and moist at first, though afterwards dry. The 
gaze is fixed, dull, and vacant ; on the other hand, we may have 
the eye dry, hot and bloodshot, the pupil contracted, the expres- 
sion wild and furtive, less commonly fierce; to this character of 
the eye is given the name of " ferrety." 

The mouth is commonly half open, the lips dry and chapped, 
and dark-colored matter collects upon them and upon the teeth 
and tongue, which is known as sordes. The odor of the breath 
and the smell of the patient's person are quite peculiar in many 
cases of typhus. It is not to be expected that all these symptoms 
will be found fully developed by the fifth or sixth day ; but it is 
very uncommon to find a case which is about to be one of typhus 
fever, pass the fifth day without presenting some, if not all, of the 
foregoing symptoms grouped together in such a manner as to 
strike the eye of a physician who has had the least experience in 
this class of diseases. 

A kind of algid condition, with coldness and lividity of the 
extremities, which we find developed in many instances, shows a 
tendency to failure of the peripheral circulation, which in ex- 
treme cases ends at a subsequent period by producing gangrene 
of the toes, feet, or legs, besides minor points of mortification in 
parts subjected to pressure. 

We will now suppose a case of typhus fever, progressing in 
the usual way, and not unfavorably, before the development of 
absolutely characteristic signs. The patient is lying in a state of 
low, half-dreaming consciousness, making no complaint, and 
seeming to have no suffering whatever; there is no local disease 
in the head, chest, or abdomen, and apparently no symptoms to 
call for medical interference in any shape; and yet even thus 



102 TYPHUS. 

early, as we shall subsequently better understand, this is precisely 
the time when acts of omission or commission by the physician 
may tell much, if not decisively, for or against the ultimate issue 
of the case. 

Eruptions in Typhus. — Between the fifth and the seventh day, 
the characteristic eruptions of typhus fever begin to make their 
appearance; they may be visible a day earlier, that is, on the 
fourth day of the disease, or their appearance may be deferred 
till the eighth; exceptional cases will also no doubt occur, in 
which it is difficult, if not impossible, to say that an eruption is 
present at any period of the disease. The general rule, however, 
is, that the eruption in typhus is first visible at some time be- 
tween the fifth and the seventh day. 

Maculae and Petechias. — At this period the spots known as "ma- 
culae," and sometimes " petechias," develop themselves on various 
parts of the body ; they are often visible first on the chest and 
abdomen in females ; in males they are more common at the out- 
set on the back, and especially in the interscapular region. From 
these parts they gradually spread to the remainder of the trunk, 
to the neck and face, to the upper extremities, and to the thighs. 
It is unusual to find them upon the hands, and the legs and feet; 
but a full crop of them is sometimes well developed in the last- 
named situation. It is not easy to reconcile the different descrip- 
tions given to us by authors of the spots known as maculae and 
those known as petechiae. For my own part, I recognize but one 
eruption of the kind now immediately under consideration, and I 
think that they may be called indifferently either maculae or 
petechiae. 

The following are the essential characters of the maculae of 
typhus ; they are commonly from half a line to a line in diameter, 
of a dusky brownish-red tint, and very slightly raised above the 
surface of the skin; they disappear upon pressure, but reappear 
immediately when the pressure is removed. They vary in quan- 
tity, being sometimes so closely set that a square inch will contain 
a dozen or more of them. In certain cases we find them of unu- 
sually large size, and then, as might be expected, they are not so 
numerous. The general eruption remains out upon the skin 
from five to seven days, but within this period there may be two 
and perhaps more successive crops of spots. 

Much may be learned from an attentive consideration of the 



MACULE OR SPOTS IN TYPHUS. 103 

spots in fever ; if of a vivid tint, raised above the skin, rapidly 
reappearing after pressure, while the general cutaneous surface at 
the same time shows a good color and temperature, the case is not 
likely to be a very severe one, or to be attended by extreme sink- 
ing ; the appearances here enumerated seem to indicate a pretty 
well sustained action of the peripheral circulation through the 
skin. If, on the other hand, the cutaneous surface be discolored, 
and the spots of a dusky brown, and still worse, if of a deep livid 
tint and large size, these appearances indicate an impure state of 
the blood, and a weakened circulation through the skin, often 
further evidenced by low temperature of the trunk, and coldness 
and lividity of the extremities. In the former case, a still vigorous 
action in the capillaries of the skin is indicative of a well-sustained 
general circulation. ' In the latter, a stasis in the minute capilla- 
ries of the skin seems the result of failing power in the central 
organs of the circulation. We sometimes meet with an eruption 
which consists of large, reddish spots, closely resembling in size 
and color those of measles ; this is known as the measly rash of 
typhus : the papulse of this eruption have a tendency to desqua- 
mate, and the skin thus acquires a sort of efflorescent appearance. 

Towards the twelfth day of the disease, or from that to the 
fourteenth, we may begin to expect the fading and final disap- 
pearance of the eruption. At this stage it may be sometimes 
noted, that the maculge change their color, and from being of a 
good, vivid, and, so to speak, healthy aspect, they become dark, 
livid, or bluish-black; this is a symptom of the very worst augury. 
A similar indication is given us in cases in which successive crops 
of dark-colored spots continue to make their appearance in the 
third week of the fever. On the other hand, the clearing away of 
the eruption by the fourteenth day, the skin at the same time re- 
assuming its natural aspect, is an indication of favorable progress, 
so far as one symptom goes. The same may be said of a change 
in color of the spots, from a dark livid tint to a more vivid hue. 

A general darkish coloration of the skin will occasionally be 
found to be persistent for many days, and even a couple of weeks, 
after convalescence is pretty well established. An indistinct mot- 
tling of the skin may be noticed in these cases, but is not to be 
confounded with the true maculae, which have usually quite faded 
by the end of the third week of the fever. 

The spots we have just described are to be met with in a very 



lOi TYPHUS. 

large number of the cases of ordinary typhus fever ; they are 
the only form of eruption which can be said to be truly charac- 
teristic of the disease, and which run a definite course. We meet, 
however, in many instances, with several other eruptions inter- 
spersed with the true maculae or petechias, and which modify con- 
siderably the appearances presented by the skin in typhus. The 
chief of these accidental and occasional eruptions are sudamina, 
or sweat vesicles, purpuric spots, in all respects similar to those 
occurring in purpura hemorrhagica ; the marks known as vibices, 
large subcutaneous hemorrhagic patches ; various erythematous 
spots and patches often occurring on parts which subsequently 
undergo mortification, sphacelus, and separation. 

Sudamina. — Sudamina, or sweat vesicles, present themselves as 
minute pearly or transparent points, containing a clear fluid, sud- 
denly occurring in connection with diaphoresis; these vesicles 
remain upon the surface for a day, or at most two days, then 
burst, discharge their contents, and leave behind a slight super- 
ficial cuticular efflorescence. The eruption of sudamina is not 
constant in typhus, and has but little practical import in the 
case, unless the fluid in the vesicles be turbid, or sanguinolent, 
the sweat secretion presenting at the same time a foul and fetid 
odor. In such a case, these phenomena must be interpreted as 
the result of the general putrescence of the fluids. Generally, as 
above stated, the occurrence of sudamina is without practical 
bearing on the case. It is needless to say, after the full expres- 
sion of our views with respect to crisis contained in this work, 
that no abortion of the fever is to be expected from the occur- 
rence of sudamina. 

Purpuric spots. — An eruption of purple spots and occasionally 
of purple patches is commonly enough found associated with the 
maculae of typhus in certain epidemics. The nature of these pur- 
puric spots seems identical with that of the spots which occur in 
true purpura hemorrhagica ; they are irregular in shape, and vary 
in size from a sixteenth of an inch to one or two lines or upwards. 
They are permanent stains, of a deep purplish or blackish-blue 
tint, and do not disappear on pressure, whereby they are at once 
distinguished from true maculae of typhus, or the rose-colored 
lenticular spots of typhoid. In the low epidemics of Ireland, 
the purpuric spots become developed at an early period of the 
fever, and are persistent throughout ; they are sometimes present 



PURPURIC SPOTS AND PATCHES IN TYPHUS. 105 

in extraordinary abundance, thickly strewn upon the face, neck, 
trunk, upper and lower extremities, and upon the anterior, as well 
as the posterior surface. It is not uncommon to find them thickly 
covering the legs and feet, and giving a peculiar aspect to these 
parts. Large purple patches, not disappearing upon pressure, 
and in no way distinguishable from those of true purpura hasmor- 
rhagica, are present in some instances upon the lower extremities, 
and various dependent parts. These purpuric spots and patches 
are derived from pathological states of the blood and bloodvessels, 
and are to be regarded in some instances as true subcutaneous 
hemorrhagic exudations; in other cases, as in a manner resulting 
from the staining of the tissues by imbibed blood. They are 
always indicative of extremely low action in the system, and are 
to be looked upon as symptoms of the very worst augury; our 
prognosis must be therefore of the most guarded kind in cases in 
which there is any very considerable eruption of purple spots or 
patches. 

Vibices. — This term has been applied to certain irregular black 
and blue patches, occurring on various parts of the surface; they 
sometimes present themselves as longitudinal streaks, similar to 
those which follow blows of a stick. They appear suddenly, last 
for some days, and gradually fade, passing through various 
shades of color, to a light lemon yellow tint, after which they 
soon vanish. Vibices seem to be essentially of the same nature 
as the purpuric spots and patches just spoken of; but in a prac- 
tical point of view, they have this essential difference; vibices 
are less numerous, they are also not unfrequently isolated, and 
confined to one or two particular spots, and the cases presenting 
them have seldom, if ever, such a tendency to low sinking action 
as those with the purpuric complication. Patches of more ex- 
tensive subcutaneous hemorrhage occasionally present them- 
selves ; thus we find the greater part of the calf, and it may be 
of the lateral and anterior surfaces of one or both legs, the seat 
of a uniform, bluish-black discoloration, which is persistent and 
not altered by pressure; the dorsum of the foot, the back of the 
hand, and various parts of the trunk, both anteriorly and pos- 
teriorly, may be the seat of similar discoloration. These exten- 
sive patches are likewise, no doubt, to be referred to a condition 
similar to that of purpura hemorrhagica. I have no observations 
to prove the occurrence of spots of this kind on the internal 



106 TYPHUS. 

mucous surfaces, but from analogy I think they must be often 
present in this condition, as we know them so commonly to be 
in true purpura, in which we often find them on the intestinal as 
well as on the peritoneal and other serous surfaces. Care must 
be taken not to confound the foregoing appearances with those 
found in parts undergoing mortification, which likewise is an 
accident to be anticipated in bad forms of typhus. 

Erythematous patches. — Spots, varying in size from half an inch 
to a hand's breadth and upwards, will be noticed in various parts 
of the body to present a reddish tint, disappearing on pressure ; 
there may be a slight elevation of the skin, with a tendency to 
efflorescence of the cuticle. When presented on the anterior 
surface, these erythematous patches are of little significance ; but 
when they show themselves upon the posterior aspect of the body, 
and especially on parts subjected to pressure, they demand our 
most immediate attention, as they are often the precursors of 
rapid and deep inflammation ending in death of the part. The 
integument about the occipital protuberance, that of the nape of 
the neck, that over the vertebra prominens or seventh cervical, 
the angles of the scapulas, the elbows, the back of the sacrum, 
the buttocks, the calves of the legs, and the thick adipose cover- 
ing of the heels, are all liable to this erythematous inflammation, 
tending to end rapidly in mortification. 

The affection known as lentigo, or freckles, tends sometimes 
to obscure the appearance of the surface in typhus cases ; freckles 
are to be recognized by their yellowish aspect, their non-disap- 
pearance on pressure, and the fact that they are present only on 
parts exposed to the sun. Flea-bites, likewise, often complicate 
the appearances in fever cases ; it is surprising in what numbers 
they will be present in patients from amongst the poorer classes, 
in whom squalid poverty offers little inducement and no facilities 
for the cultivation of personal and domestic cleanliness. Flea- 
bites, when recent, exhibit circular spots half a line in diameter, 
of a rose-pink color, disappearing on pressure, and exhibiting a 
minute central point ; by these characters they can be readily 
known. 

Individually followed up in the way we have attempted to 
describe them, the various eruptions occurring in typhus can be 
distinguished and identified without much difficulty ; but the 
student and junior practitioner will often find it a puzzling task 



STATE OF THE TONGUE IK TYPHUS. 107 

to unravel the various complicated appearances presented in a 
suspected case of typhus, and to say whether there be or be not 
an eruption of true maculse or petechias, which would enable him 
to form a positive diagnosis as to the nature of the case before 
him. A case on the seventh or eighth day of typhus, with an 
abundant crop of maculae, purpuric spots and patches, vibices, 
freckles, and flea-bites, often requires no small experience and 
careful study of its phenomena before a diagnosis can be posi- 
tively affirmed. 

The appearances of the skin are not less important in regard 
to prognosis ; they will often aid us in forming a reliable opinion 
as to the course a case is likely to take. In general it may be 
said that cases of typhus with dusky and much congested skin, 
tendency to coldness in the extremities, and exhibiting copious, 
complicated, and livid eruptions, sink early, and are very fatal. 
On the other hand, where the cutaneous circulation is well main- 
tained, and the eruptions single, not too thickly strewn, and of 
a florid tint, the patients do well, unless there be serious internal 
complications. 

State of the Tongue. 

Most valuable indications may be obtained in typhus, from 
carefully observing the condition of the mouth and tongue. 
When the pyrexial state is first developed, the tongue is often 
soft and creamy ; as the case goes on, the secretions about the 
lips, teeth, and internal portions of the mouth accumulate, owing 
to the suspension of the finer sensibilities of the parts, and the 
arrest of those minor involuntary movements, hardly noticeable 
in the time of health, but which, by the constant action of the 
lips and tongue, keep the parts clear of epithelial debris, saliva, 
&c. If we watch attentively the face of a person in typhus, we 
may remark, besides the symptoms already noticed, much insen- 
sibility to external impressions ; thus the patient will sometimes 
take no heed of the fly that crawls over the eyelids, upon the 
nose, or it may be in and out of the mouth. The eyelids and 
lips are but seldom moved, and then but sluggishly and imper- 
fectly ; he breathes by the mouth as much as by the nose. As 
the result of this, epithelial debris, saliva, and the tartar of the 
teeth accumulate, and crust upon the lips, gums, and tongue. 



108 TYPHUS. 

They become blackened and decomposed, and emit an impure 
odor. The secretion on the tongue undergoes similar changes ; 
the term sordes (filth) is applied to the foul encrusted secretion 
upon the lips, teeth, and tongue; it sometimes accumulates in 
considerable masses, and requires to be removed. 

After the creamy state of the tongue, we next find this organ 
presenting a still moist, bat thick and dirty, brownish coat. In 
some cases the tongue is thickly coated with sordes, but is still 
moist and of its natural volume, or slightly marked on the sides 
with the impressions of the teeth, showing that it is a little en- 
larged. A state of the tongue is not unfrequently met with in 
which it is dry and cracked, contracted in volume, and pointed ; 
there is but little coating upon it, and the condition of the organ 
reminds us of that presented by the parrot's tongue, and hence 
this condition of the tongue in fever has been designated by the 
French as la langue perroquet^ or parrot's tongue, an expression 
which conveys a very good idea of the state of the organ. The 
hard, dry, brown, mahogany state of the tongue, is another con- 
dition of the organ which requires particular notice : the tongue 
is thickly crusted with dry sordes: it is sometimes fissured, and 
occasionally exudes blood ; the color is peculiar, and is well con- 
veyed by the term mahogany. This state of the tongue is of great 
practical importance as an indication for treatment : cases ex- 
hibiting this condition of the organ will often be found to require 
the liberal use of stimulants, and to bear them well. The last 
condition of the tongue which requires notice, is that in which 
we find the organ in a weakened and semi-paralytic state. It is 
tremulous, and the patient protrudes it with difficulty, and un- 
certain motion, as if he had almost lost control over it. This 
tremulous and semi-paralytic tongue may be either moist, and of 
natural volume, or coated, dry, and fissured; as far as a single 
symptom goes, it is one of very bad omen, and indicates a. very 
low state of the system. 

Attention to the characters presented by the tongue as above 
detailed will give us most valuable hints in the course of fever, 
but we must always remember that the indications derived from 
any one organ are only to be correctly interpreted by taking 
them in connection with those furnished by other parts of the 
system. 



TENDENCY TO SINK IN TYPHUS. 109 

We are now in a position to take a view of the more impor- 
tant phenomena presented to view by a well developed case of 
low typhus, about the eighth or ninth day of the disease. We 
will suppose the patient to exhibit the characteristic typhus pros- 
tration in a well-marked degree, the skin being profusely macu- 
lated, and spots of purpura li(Bmorrhagica developed upon the 
lower extremities and elsewhere upon the surface, with two or 
more purpuric patches ; or vibices, disseminated here and there. 
(The purpuric appearances are of course not developed except in 
very low states of the system.) 

The patient lies in a half-conscious state, perhaps occasionally 
muttering, but making no complaint, and suffering little ; he is 
easily roused, answers coherently, but relapses immediately into 
his dreamy, half-conscious state. The pulse is quick, 120 to 130; 
it is weak and devoid of resiliency, but may have some volume. 
It is, however, readily extinguishable by slight pressure in most 
cases of the kind now under consideration. The patient is in all 
respects in a passive state, takes food, drink, and medicines when 
offered to him, and makes no resistance when any ordinary offices 
are performed for him by his friends or attendants. If carefully 
observed, it will be found that many patients in this state, though 
quiet and almost unconscious by day and night, get little or no 
continuous sleep ; they doze for a short time, but there is no un- 
broken or refreshing sleep. Without actual delirium, there is 
occasionally much rambling, and the patient is often subject to 
various hallucinations and illusions, which, however, are dispelled 
when he is roused, called by name, or otherwise forcibly ad- 
dressed. In the condition here but imperfectly described, many 
patients will go on from day to day, without the supervention of 
any new symptoms, and without anything that will alarm the 
friends, or the physician inexperienced in the pathology of 
typhus. It will be soon manifest, however, that the patient is 
losing ground, he is becoming weaker and weaker from day to 
day ; he is sinking slowly, imperceptibly, but surely ; at last the 
vital powers become exhausted, and he dies out on the 13th or 
14th day. " He goes out like the snuff of a candle," as it is 
forcibly and characteristically expressed. This is the history of 
no inconsiderable number of fatal cases of typhus fever in all 
epidemics ; these are cases of a very treacherous nature, and for 
which nothing but a large experience of the disease will prepare 



110 TYPHUS. 

us. There are few practitioners who have not to admit that cases 
of this kind have slipped through their hands, almost without 
their suspecting the formidable character of the disease. 

In other instances, with judicious care, the liberal use of stimu- 
lants, and an early anticipation of this tendency to low sinking 
of the system, cases of typhus will be brought to a favorable 
issue at some period between the 11th and 21st days; the erup- 
tion gradually fades, the patient slowly emerges from the state of 
prostration, and the nervous and circulating apparatus become 
gradually restored to energetic and healthy action. In either of 
the two events just indicated the case is a true exemplification of 
a pure, uncomplicated, essential fever, progressing to a termina- 
tion, whether by death or recovery, without a single organ or 
tissue in the body being implicated in any process of disease 
whatsoever. This,, in fact, may be looked upon, so to speak, as 
the normal course of typhus fever. The system undergoes a 
general process of diseased action, the main features of which are 
extreme and intense prostration of the nervous energies, and 
which is attended by increased metamorphosis of the tissues 
throughout the body, but is wholly independent of recognizable 
lesion in any part or organ after death. In fatal cases of this 
kind we examine all the organs in vain to discover the cause of 
death : the brain and spinal marrow are free from disease ; the 
lungs, except hypostatic congestion of the posterior lobes, pre- 
sent no pathological state ; the heart is often healthy, but, as will 
be subsequently explained, this organ perhaps more frequently 
than any other presents certain changes : in the abdominal cavity, 
the solid and hollow viscera present no departure whatever from 
a condition of perfect health. Normal Typhus, then, it is beyond 
all question, may run its course, and prove fatal from extreme pros- 
tration of nervous power, without the slightest lesion being discoverable 
in any part or organ after death. 

Pure uncomplicated typhus fever is, however, far from being 
commonly met with : for while pure uncomplicated typhus is to 
be regarded as the normal type of the disease, the cases met with 
in practice present a singular tendency to the development of 
incidental lesions affecting now this organ, now that. Thus we 
shall find that in one class of cases, or at one period of an epide- 
mic invasion, head symptoms with delirium are commonly asso- 
ciated with the fever : in other instances it is the lungs which are 



SECONDARY LESIONS OF TYPHUS. Ill 

specially affected ; under circumstances still more rare, the intes- 
tinal mucous surface may be the seat of secondary lesion. We 
find then, on the one hand, that it is necessary for a true concep- 
tion of the nature of this fever to consider it as an essential 
disease of the whole system, not originating in special lesion in 
any one part or organ. It is equally important, on the other 
hand, in our clinical consideration of typhus, to know that it is a 
disease which, while following out a definite course of its own, 
may incidentally lead to the development of various lesions, 
which may affect indifferently any organ in the body, but have in 
certain epidemics, and in certain classes of individuals, a prone- 
ness to invade certain organs to the exclusion of others. 

The lesions now spoken of play, in one sense, a secondary part 
to that which the fever itself performs ; they do not belong to the 
fever, they may be altogether absent without impairing its true 
character ; they are therefore properly designated as the secondary 
lesions of typhus fever. 

SECONDARY LESIONS OF TYPHUS FEVER. 

The Secondary Lesions of typhus fever implicate almost all 
organs in the body ; we propose to enter on their consideration 
in the following order : — 

1. Secondary Lesions of the Cerebral Organs. 

2. Secondary Lesions of the Circulating Apparatus. 

3. Secondary Lesions of the Lungs and Pleurae. 

4. Secondary Lesions of the Intestines. 

5. Secondary Lesions of the Solid Viscera, including the Liver, 
Spleen, and Kidneys. 

6. Secondary Lesions of the Cutaneous System, including 
bed-sores, mortification of the extremities, and certain minor 
conditions. 

"We saw that it was the prominent characteristic in many cases 
of pure typhus, uncomplicated with local affection, that there was 
a disposition to sink and for the vital spark to go out, as it were, 
life becoming extinguished almost imperceptibly and insensibly, 
and without any accession of violent symptoms, and often indeed 
without any apparent cause at all, except the excessive weakness 
and utter prostration which the patient's system undergoes. This 
is not uncommon in the typhus of the upper and middle classes, 



112 TYPHUS. 

but it is far more usual to find that the case presents, and this from 
an early period, some one or more of the local affections in the 
various organs just enumerated, as the head, lungs, and heart, and 
abdominal organs. 

What, it may be asked, is the nature of these local affections ? 
They are not part of the fever, they have no necessary connection 
with it, for we have seen that pure typhus may go on to the end, 
and issue in death or recovery, without them. They are not in- 
flammations in the strict sense of the term, and yet we have no 
other pathological condition under which to range them. 

These secondary lesions of typhus present many features in 
common amongst themselves ; and by which they are well dis- 
tinguished from ordinary inflammations. 

(a.) They are marked by the suddenness of their invasion, and 
the absence of premonitory symptoms. 

(b.) They present an abnormal course, and not unfrequently a 
suppression of one or more of the stages which similar processes 
of disease exhibit in the healthy organism ; in other words, the 
secondary lesions of typhus have a kind of abortion of their first 
stage, and the organs which they attack are suddenly precipitated 
into an advanced condition of disease. 

(c.) The secondary lesions of typhus often present abnormal 
characters in their signs and symptoms: they likewise are but 
little under the influence of depletion and other antiphlogistic 
measures, while stimulant treatment has a singularly favorable 
influence upon them. 

(d.) They are characterized by a common tendency to rapidly 
fatal issue, and in post-mortem examination it is not unusual to 
find that the anatomical lesion is wholly disproportionate in ex- 
tent to the exaggerated symptoms present during life. 

HEAD SYMPTOMS AND CEREBRAL COMPLICATIONS IN TYPHUS. 

Head symptoms of a very formidable class not unfrequently 
present themselves in certain cases of typhus. It is a very im- 
portant observation, and one well borne out by the experience of 
practical men, that head symptoms are more often met with, and 
are more often fatal, in the upper than in the lower classes of 
society. Few of the physicians who fought the good fight against 
disease in any of the great epidemics of these countries, especially 



CEREBRAL COMPLICATIONS IN TYPHUS. 113 

in Ireland, can fail to recognize the truth of this observation. In 
periods of great epidemic visitations, the typhus attacks all classes 
of society indiscriminately, respecting neither age nor sex, and 
invading the mansions of the rich as well as the squalid hovels 
of the poor ; but its death-blows seemed to be dealt with a dis- 
criminating hand. 

Thus we find that typhus proves fatal by cerebral complica- 
tions, in the better classes of society, as constantly as by thoracic 
secondary lesions amongst the lower classes. It may be that 
those organs which are in the highest state of physiological ac- 
tivity in the condition of health, are the most prone to disease, 
and that, as the cerebral organs are more exercised amongst the 
better classes, they are more readily seized upon by the typhous 
influence when it pervades the system. Certain it is, that amongst 
the many gifted and noble-minded: individuals who have fallen 
victims from time to time to the typhus of this country (Ireland), 
the cerebral symptoms in the majority of instances have been 
those which ushered in the fatal termination. 

The slightest form of cerebral and nervous excitement which 
we meet with in typhus, is that in which there is constant low 
muttering delirium, but the patient lies tranquilly in bed, and 
will answer coherently if strongly roused. In this state the 
patient may pass days in succession, getting some occasional 
hours of quiet and refreshing sleep : such cases are not very for- 
midable. The next variety of case is that in which we have 
sleeplessness superadded to the delirium : under these circum- 
stances, the patient becomes restless, irritable and excited, and 
the delirium assumes the character of being watchful and furtive; 
sometimes the patient is timorous, sometimes he is disposed to be 
violent and uncontrollable. The eye now assumes an altered 
expression ; it is no longer half-closed and semi-conscious, but 
watchful, restless, occasionally brilliant and fierce-looking, and 
sometimes of the kind known as " ferrety," the pupil being con- 
tracted and the conjunctiva injected. The patient is often under 
the influence of hallucinations and illusions, which, in a rambling 
way, he communicates to those around him. 

It is well to indulge these impressions on the part of the patient, 
within certain limits, with a view to tranquillizing him ; but I 
have known instances in which a patient, with an instantaneous 
return of consciousness, loudly upbraiding the nurse for bad faith 



114 TYPHUS. 



in aiding him to deceive himself with the imaginings of his 
fevered brain. Cases of this kind require much skill and tact to 
manage them, as waste of vital energy from nervous or mental 
excitement is followed by great prostration, and occasionally by 
fatal collapse. 

The next important variety of cerebral and nervous excitement 
in typhus, is one which closely resembles the condition of delirium 
tremens ; indeed, it would be no misnomer to designate the condi- 
tion we are now about to consider the delirium tremens of typhus. 
I have most often seen this condition to supervene at the end of 
the second week or the beginning of the third week. The 
patient is usually much debilitated, the pulse is feeble and quick, 
at or over 130 ; the surface is moist and clammy, and there are 
occasional paroxysms of sweating; the countenance is anxious, 
and the expression betrays fear and apprehension ; the eyes are 
restless, furtive, and suffused. The patient is fidgety and restless, 
sometimes half sitting up in the bed, sometimes watching an 
opportunity of getting out of bed for some ill-defined purpose; 
but it is worthy of note, and highly characteristic of this state, 
that the patient is easily cowed by a gesture of command, and a 
firm look or word. In this respect the delirium tremens of 
typhus is very analogous to that of the dipsomaniac. There is 
often a general tremor of the limbs, and a tremulous state of the 
tongue. The cardiac action in these cases is often violent, but 
excessively feeble, and the patient is altogether in a condition of 
the most extreme danger ; the nervous energies are in fact on 
the point of giving way, and in many instances the patient's life 
hangs literally by a thread. 

We have now to notice a condition of high excitement in 
typhus, the symptoms of which are of even a still more urgent 
kind; they resemble somewhat, and are constantly taken for, 
those of phrenitis, and it is this class of cases which, par excellence, 
are- "usually regarded as examples of "brain fever" so called. 
There is usually an increase of the high pyrexial excitement; 
the skin is hot, and the face flushed ; the pulse is full, strong, 
120 to 130 ; the heart's action violent, and there is throbbing of 
the temples and of the vessels in the neck. Headache, general 
or frontal, pains in the eyeballs, intolerance of light, contraction 
of the pupil, brilliancy of the cornea, and congestion of the 
conjunctiva, are also well-marked features. The expression of 



DELIRIUM FEROX OF TYPHUS. 115 

the eye is bold and fierce, the delirium which supervenes is per- 
sistent; it is also of an active and threatening nature, and nothing 
short of physical restraint in many instances prevents the patient 
from doing injury to himself or others. This is the true delirium 
ferox of typhus; the patient raves constantly, and it is impossible, 
as in the states hitherto considered, to get coherent answers from 
him. 

He wildly tosses about his head, trunk, and limbs ; in the 
worst cases there is complete insomnia; and for days and nights 
together the patient does not get an hour's sleep. The muscular 
efforts of the patient are surprising, and it will often require the 
united strength of three or four attendants to keep him in bed; 
a strait-waistcoat is the safest means in such cases. Nothing can 
be more trying to the medical attendant than the care of a typhus 
patient under the circumstances which we are now but feebly 
endeavoring to portray. He can hardly leave his patient for a 
moment, and yet can often effect but little by his presence. Hour 
by hour he sees his patient expending the last remnant of his vital 
powers in high-strained and violent exertions of nervous and mus- 
cular force. To the state we have just described often succeeds 
a short interval of profound prostration and collapse of all the 
vital energies, and in a few hours subsequently the patient dies 
out, utterly exhausted, the last vital spark becoming almost in- 
sensibly extinguished. In other instances, a state of coma super- 
venes, with total insensibility, dilatation of the pupils, stertorous 
breathing, and it may be a relaxation of the sphincters. I have 
occasionally witnessed in association with this state of things a 
low moaning of a peculiar kind, and a rolling of the head from 
side to side, which continued for clays and nights, to cease only 
at death. 

Besides the states above described, we meet with incidental 
forms of nervous derangement in fever. Under this head may 
be classed tonic and clonic spasms, and other convulsive affec- 
tions, jactitation of the limbs, and floccitatio, or involuntary pick- 
ing of the bedclothes. Paralysis of the sphincters of the rectum 
and neck of the bladder is often met with; involuntary motions 
from the bowels, and the dribbling of urine are very trouble- 
some affections, soiling the patient's bed and person, and if con- 
stant attention is not given to the patient, irritation and excoria- 
tion of dependent parts often ensues. The state of the bladder 



116 TYPHUS. 

and urinary apparatus in typhus is more fully described in a 
subsequent section. 

The pathology of the cerebral lesions of typhus still rests on 
somewhat debatable ground. Of one position, however, I am 
myself perfectly confident — namely, that they are not true inflam- 
mations ; and it is certain that if we treat them as inflammations, 
and by the antiphlogistic method, we shall lose a large proportion 
of the so-called brain fevers. It has been well and profoundly 
observed by Stokes, that those symptoms which indicate inflam- 
mation under ordinary circumstances, do not indicate inflamma- 
tion when the case is one of typhus fever. We may appeal, 
again, to the researches of Louis for confirmation of these views 
in respect to the cerebral symptoms in fever. In the extensive 
pathological observations which I have myself made, the absence 
of any connection between cerebral symptoms during life, even 
when of an aggravated kind, and inflammatory lesions in the brain 
and its membranes after death, has been noted in many forms of 
fever. Numerous dissections warrant me in stating that I have 
found sensible congestion of the brain and its membranes with 
increased serosity in the ventricles and subarachnoid spaces in 
cases which had presented no cerebral symptoms whatever during 
life; and again, that where there had been delirium ferox, and 
even in more than one instance coma, no appreciable lesion could 
be detected in the brain or spinal cord after the patient's death. 
This may seem paradoxical, but it is based upon fact ; and the 
conclusion is simply this, that in respect of typhus fever, at all 
events, true inflammation of the brain and its membranes is of 
very rare and exceptionable occurrence. Many of the cerebral 
symptoms in typhus are explicable on the supposition that they 
are caused by a temporary congestion of the intra-cranial vessels ; 
others, it is equally probable, are due to diminished nutrition of 
the brain, from its receiving an impure and inadequate supply of 
blood ; a third class of cases, including those with comatose and 
paralytic symptoms, may be traced to the influence of the highly 
carbonized and otherwise deteriorated blood which is sent to the 
brain and the spinal cord. 

Whatever their pathology, the clinical importance of the cere- 
bral lesions of typhus cannot be over-estimated ; they are common 
to this fever in all ages and sexes, but we have already remarked 
on their greater frequency and fatality amongst individuals in the 
better classes of society. 



TREATMENT OF CEREBRAL SYMPTOMS IN TYPHUS. 117 

In the simpler forms of the cerebral affections of typhus, mild 
measures and judicious and watchful attention to the patient will 
often effect much. If there be headache and throbbing of the 
temples, cold evaporating lotions will be useful. 

In a considerable number of cases, the milder cerebral affections 
seem to be associated with morbid states of the primae viae. Thus, 
an overloaded stomach, or a confined state of the bowels, will be 
found to keep up excitement of the brain, delirium, and sleepless- 
ness; the remedy is obvious, and a judicious purgative draught, 
or a turpeDtine enema, will be followed by a complete remission 
of the head symptoms, the patient sinking into a tranquil sleep 
after the bowels have been moved. We must not, however, omit 
to notice that an opposite state of the primae vias, or that in which 
gastric irritation with vomiting and diarrhoea is present, may also 
react through the chain of the vagi upon the brain. Here the 
obvious indication is to allay the gastric irritation by sedative 
draughts, iced drinks, counter-irritation over the epigastrium, 
and means directed to control the intestinal irritation of which 
the diarrhoea is but a symptom. We must remember that in 
many cases the abdominal symptoms now alluded to are conse- 
quent on the abuse of emetics and purgatives at the outset of the 
fever. In not a few cases of fever, cerebral symptoms with mut- 
tering delirium and sleeplessness result from over-exertion of the 
brain and mental faculties. The following is not an uncommon 
occurrence : the patient has reached the ninth or tenth day of his 
fever without bad symptoms ; he is doing well to all intents and 
purposes; he is tranquil and collected, and alive to all that passes 
around him ; troops of friends have daily besieged his doors with 
anxious inquiries, and it is thought that the time is come when 
he may now surely see one or two of his most intimate associates. 
The barrier once broken, there is no limit to the agreeable excite- 
ment; the patient's energies are roused in a manner that surprises 
himself and his friends ; but to this day of excitement succeeds a 
night of prostration, with sleeplessness and waking hallucinations, 
if not actual delirium. Not a few of these cases are observed to 
go rapidly to the bad. It must be made a rule in the treatment 
of fever cases never to let the patient see or converse with any 
one, except his nurse and immediate attendants, before one o'clock 
in the day or after two ! 

There is another set of cases in which, no doubt, temporary 



118 TYPHUS. 

congestion of the brain will require the application of a few 
leeches — three to five — to either or both temples. 

In cases with marked rapidity of the circulation, the cerebral 
symptoms appear to depend upon defective blood supply to the 
brain. It is under these circumstances that the cerebral symp- 
toms of typhus present such close resemblance to those of the 
delirium tremens of the dipsomaniac. If such a case be bled from 
the arm, or that blood is largely abstracted by leeches, or cupping 
from the temples, we but add to the mischief, and the nervous 
excitement, tremor, and sweat become still more aggravated. 
Shaving the head, and the application of the cold douche, or the 
ice-cap, blisters, tartar-emetic ointment, and such means, are also 
unproductive of good, and often dangerous. On the other hand, 
judicious stimulation is frequently the best means for controlling 
the state of nervous excitement under which the patient labors. 
It not unfrequently happens that the symptoms we are describing 
— viz., delirium tremens, sweat, and feeble circulation, with rest- 
lessness, sleeplessness, and muttering delirium — supervene in 
cases in which the lancet and other depletory measures have 
been abused in the early stages of the fever, while proper nourish- 
ment has been withheld from the patient all through under similar 
erroneous views. Now the way to remedy this state of things, 
is not by further lowering of the system of the patient by bleed- 
ing, purgation, and starvation, but by the liberal use of nourish- 
ing broths, and stimulants, including wine, brandy, whiskey, 
ammonia, ether, singly or combined, as the urgency of the case 
may require. Thus in a case of private life, half a bottle of mild 
but generous claret will be the best sedative which can be admi- 
nistered to the patient ; a strong tumbler of brandy or whiskey 
punch will in severe cases have a like effect. "We may judge 
that stimulants are acting well, when the pulse sinks five or ten 
beats, and at the same time expauds in volume, the nervous 
excitement, sweat, and tremor disappearing, while the patient 
gradually sinks into a profound and refreshing sleep. The use 
of stimulants, under the circumstances now indicated, requires a 
combination of boldness and discretion on the part of the physi- 
cian, while an acute judgment and much experience are indis- 
pensable ; and yet under no circumstances will more decisive 
results be obtained from bold and well-directed treatment. 

There is a variety of the cases last considered in which nervous 



USE OF OPIUM IN TYPHUS. 119 

excitement, apart from debility, is the preponderating feature ; 
the vascular system may not be greatly depressed, and the pulse 
will be found moderate in volume and frequency. In many of 
these cases, musk is the drug which seems to act with the most 
specific virtue; it may be ordered in from two to five grain doses, 
given every hour or every second hour, according to circum- 
stances; it may likewise be administered, suspended in some fluid 
vehicle, one to two scruples in a six or eight ounce mixture, with 
an ounce of mucilage to aid its mechanical suspension. It has 
been given in larger doses, but not with sufficient reason, in my 
opinion. 

Opium, and the preparations of morphia, may often be used 
with benefit where the nervous phenomena preponderate; thus 
half a grain of opium, or from a quarter to half a grain of the 
muriate or acetate of morphia, may be given in pill at bedtime ; 
larger doses may be occasionally useful, but we must bear in 
mind that opiates are entirely contra-indicated where there is 
any tendency to venous stagnation in the cerebral organs. Some 
writers of great authority even go so far as to proscribe altogether 
the use of opiates in fever, through an apprehension that they 
tend to produce venous congestion, if not coma ; but I think 
that this apprehension is not sufficiently well grounded : un- 
doubtedly opiates are not applicable to every case of fever, and 
are entirety contra-indicated when there is the slightest tendency 
to venous congestion, as above explained. 

We have still to speak of the formidable class of cases in 
which the cerebral symptoms take the form of delirium ferox, 
with maniacal excitement, a wild and fierce expression of the 
eye and contracted pupil, while the combative and destructive 
faculties are roused, and the patient puts forth nervous and mus- 
cular exertions to a surprising degree. The symptoms which 
the patient now presents are entirely different from those exhi- 
bited in the condition above described as the delirium tremens 
of typhus. In this latter state he is fearful, and easily cowed, 
though his delirium may be busy, threatening, and even mis- 
chievous, when he is left alone for a while ; but a word or a look 
from his attendant sends him cowering under the bedclothes, In 
the delirium ferox, on the other hand, the patient often no longer 
recognizes any one, and can only be controlled by physical force; 
he is perpetually getting out of bed, and, for want of proper 



120 TYPHUS. 

attendance, fatal accidents have occasionally happened ; as, for 
instance, from the patient getting possession of a razor or other 
cutting instrument, or throwing himself from a window. These 
cases present undoubtedly not a few points of resemblance to 
cerebritis or inflammation of the brain ; we must only refer to 
what has been already said on a former occasion on this subject. 
The means usually employed to combat this affection are, general 
venesection, shaving the head, and the application of leeches, the 
ice-cap, cold affusion, and blisters or tartar-emetic ointment. 
With the exception of venesection, which I for one entirely 
repudiate in the treatment of typhus, each of the other remedies 
is well deserving of attention. In reference to shaving of the 
head, it may be here mentioned that we may dismiss from our 
minds all considerations as to sacrificing unnecessarily this 
natural ornament of the human person. After almost any fever, 
the hair, as well as the general cuticle, is shed : shaving is the 
means which will best promote an abundant re-growth of the 
hair. If, therefore, we shave the head in fever, we are only 
anticipating what will ultimately have to be done. At the same 
time I am no advocate for the cruel and indiscriminate shaving 
of the hair, so often unnecessarily practised amongst the poorer 
classes. We must remember that if the fever be not fatal, the 
patients will, in all probability, have to leave hospital in a month 
or six weeks, and long before the hair is sufficiently grown again 
to afford to the head its natural covering and protection. 

Leeches to the temples are undoubtedly efficacious in some in- 
stances, but in others the abstraction of even a small quantity of 
blood seems to aggravate the symptoms ; there is often, likewise, 
much difficulty in applying leeches to the temples when the pa- 
tient is in a state of violent delirium and offering great resistance. 
I make no mention of bleeding from the temporal arteries, as I 
consider it a wholly unjustifiable proceeding in cases of typhus. 
Cold affusion, which may be effected by pouring two or three 
quarts of water on the patient's head out of a jug from a mod- 
erate height, is a powerful agent, and must be used with great 
caution. Evaporating lotions and the ice-cap, made by tying up 
pounded ice and salt in a bladder, are useful applications, and 
often tranquillize the patient a good deal. Blisters and tartar- 
emetic ointment are more appropriate for cases in which there is 
a tendency to coma from venous turgescence, or effusion of serum 



TARTAR EMETIC AND OPIUM IN TYPHUS. 121 

into the ventricles. Under such circumstances, when the pupil, 
previously perhaps much contracted, is beginning to dilate (with 
or without a partial strabismus), and the breathing to assume a 
stertorous character, while the patient, from a state of violent 
delirium and nervous excitement, is becoming insensible, we must 
have recourse to rapid and free counter-irritation over an exten- 
sive surface of the shaven crown, by emplastrum lyttse, acetum 
lyttse (very cautiously applied), or by sinapisms, or more slowly by 
the inunction of tartar-emetic ointment. Cold affusion, performed 
from a height with a good volume of water and in a full stream, 
acts occasionally as a powerful excitant to the brain, and seems 
to arrest the comatose tendency. The shock which it occasions 
on the system in some is not free from danger, and it is at best 
but an anceps remedium. Mercurial inunction to the axillae and 
groins is often had recourse to in these extreme cases; mercury 
internally administered is also spoken of with favor in similar 
circumstances by some authors. It is directed to meet cerebral 
inflammation, but as we have seen that this condition is one of 
the utmost rarity in typhus, I cannot concur in the opinion that 
mercurialization is based on a rational view of the pathology of 
this class of cases. 

But there is a still more formidable condition than any we 
have yet considered; no language can adequately picture the 
state of things we are now about to describe. You are summoned 
to a case in fever at about the eleventh or twelfth day of the dis- 
ease; you find the patient half sitting up in bed, violent and un- 
manageable, sometimes screaming and terrified, at other times 
in the most furious condition of maniacal excitement, and barely 
restrained in bed by the united exertions of two or three assist- 
ants. The pulse is feeble and rapid, 130 to 140, and the patient 
is sweating profusely. No more desperate condition of things 
can be well conceived, and there is scarcely any position more 
embarrassing for the attending or consulting physician. What 
can be done under such circumstances, which will offer a chance 
of saving the life of the patient, whose system is working at a 
fearful rate of high-pressure energy, and, like some delicately 
organized machine, will wear itself to pieces within a very short 
time, if its action cannot be brought under control ? The diffi- 
culty of the medical attendant's position is still further increased 
in those cases in which he finds, on coming to apply himself to 



122 TYPHUS. 

the question of treatment, that almost every conceivable means 
has been already employed. Thus he will find that in some in- 
stances blood has been abstracted from the temples by leeching, 
cupping, or section of the temporal arteries; in some cases 
venesection will have been practised from the arm, and in most 
instances, shaving of the head, cold affusion, the ice-cap, exten- 
sive blistering, or tartar-emetic ointment will have been employed, 
singly or combined in various ways. Mercurialization will have 
been attempted, in all probability, by the administration of the 
drug internally or by inunction, or in both ways. Musk, opium, 
and camphor will have been employed with a like want of 
success. Such a case will seem all but hopeless ; medical interfer- 
ence appears but to aggravate the symptoms, and nothing appa- 
rently remains but to abandon the patient to his fate. Nil desper- 
andum must, however, be the motto of the physician in this and 
many another crisis of his professional career. Art has still one 
remedy in store, and we possess yet one means more for com- 
bating this formidable affection, which we owe to the bold and 
fertile mind of the late Dr. Graves of Dublin. For the treatment 
of cases such as we have just described, Dr. Graves proposed, and 
used with great success, a combination of tartar emetic and opium. 
It may seem to be an empiric remedy, but I think its action may 
be explained on rational principles; and of its efficacy I can 
have no manner of doubt whatsoever, for I have over and over 
again employed it with a success that seemed as magical as it was 
unexpected. 

The combination of tartar emetic and opium may be used as 
follows, viz., one drachm of the tincture of opium, with four 
grains of tartar emetic, in eight ounces of camphor mixture ; of 
this let the patient take one tablespoonful every hour, or second 
hour, according to circumstances. Vomiting is usually induced 
after the second or third dose, and a purgative effect a short time 
afterwards ; the evacuation of biliary matter in both directions is 
a decidedly favorable indication. If the medicine acts well, the 
patient becomes gradually more tranquillized, the violent nervous 
excitement subsides; the pulse falls from 15 to 20 beats in a 
minute, that is, from 140 to 120, and becomes softer and fuller at 
the same time; the patient soon breaks out into a warm and com- 
fortable perspiration, and, at the end of three or four hours, sinks 
gradually into a quiet and profound sleep. He may have been 



TAKTAK EMETIC AND OPIUM IN TYPHUS. 123 

five days and as many nights without closing an eye, raving, 
screaming, and unmanageable, even in a strait-waistcoat, and now 
in a few hours, and with an effect little short of magical, he wakes 
from a deep, long, and refreshing sleep, calm, conscious, and con- 
valescent. I am aware that there are those who still doubt the 
appropriateness and the efficacy of this plan of treatment; I have 
seen it used, and I have used it myself with the marked results 
above stated, and I feel it to be a bounden duty thus publicly to 
testify to its value. 

The proportion of the tartar emetic and opium in this combina- 
tion may be varied, according to the urgency of the symptoms. 
Two grains of tartar emetic to a drachm of tincture of opium in 
an eight ounce mixture, given in tablespoonful doses, will insure 
a moderate emetic and purgative effect. Four grains of tartar 
emetic, with two drachms of the tincture of opium, in an eight- 
ounce mixture, and given as above, will be a full dose of either 
drug; in very urgent cases a tablespoonful of this combination 
may be given every half hour ad effectum. In a case of extraor- 
dinary urgency, and in an all but desperate condition, such that 
the late Sir Philip Crampton, Surgeon General, considered that 
even a very few leeches would have killed the patient, Dr. Graves, 
en desespoir des causes, as it seems, ordered eight grains of tartar 
emetic, with one ounce of syrup of white poppies, with one of 
mucilage and six of water. Of this mixture a tablespoonful was 
given every half hour; but though slight nausea was produced, 
the patient did not vomit until after the seventh dose ; the eighth 
dose produced copious vomiting of mucous and bilious fluid. 
This appears to have been one of those dreadful cases in which 
the patient, overcoming all resistance, gets out of bed, and, with 
no other covering but his night dress, forces his way through the 
house. After the second vomiting he was so far tranqillized as 
to allow himself to be put to bed. In all, this patient took twelve 
grains of tartar emetic, the use of which was extended over near 
three days ; he ultimately recovered, and the case is one in every 
respect most remarkable and instructive. There is some reason 
to think that a combination of musk and tartar emetic produces 
somewhat analogous effects on the animal system. Dr. Graves 
remarks on the smallness of the quantity of opium which is suf- 
ficient to induce sleep in this combination: the physiological 



124 TYPHUS. 

effect of the tartar emetic is likewise worthy of note ; under its 
action the pulse is speedily reduced in frequency, while it is in- 
creased in volume. 



SECONDARY LESIONS OF THE CIRCULATING ORGANS. 

Under this head we have to consider several important lesions 
of the circulating apparatus, and which affect both the central 
organs and the peripheral circulation. The following are the 
principal forms of lesion affecting the circulating apparatus which 
we find to occur in the course of a case of typhus, viz : — 

1. A general feebleness of the circulation, as shown by frequent 
but feeble pulse at the wrist, feeble but equable pulsation in the 
various subcutaneous arterial trunks, and a corresponding feeble- 
ness of the cardiac impulse, the sounds still retaining their natural 
proportions. 

2. A state in which there is a want of uniformity in the force 
and volume of the pulse in various arterial trunks. 

3. A state in which there is, as it were, an opposition between 
the state of the pulse and that of the heart. This may be pre- 
sented in two ways; for instance, we may have a heart acting 
with great apparent intensity, the impulse in the precordial region 
being violent and tumultuous, while the pulse at the wrist is 
exceedingly weak, and in some instances all but extinguished. 
Again, we meet with cases in which the radial, carotid, or other 
vessels seem to be acting with redoubled energy, and yet, when 
the hand and stethoscope are applied to the precordial region, we 
have unequivocal evidence that the action of the ventricles is 
feeble to a degree. 

4. A state in which the failure of the circulation seems to 
commence at the heart, and in which there is good reason to 
believe that the muscular texture of the heart is itself seriously 
implicated, the impulse and first sound being altered in character, 
sensibly diminished, or, it may be, wholly suppressed. 

5. States in which, subsequent to the true typhus period, modi- 
fication of one or both sounds of the heart is observed for a cer- 
tain time. 

It is not easy to fix a standard for the pulse in typhus ; a safe, 
and, so to speak, normal state of typhus is attended by a pulse of 
moderate volume and force, and which is usually somewhat under 



LESIONS OF THE HEART IN TTPHUS. 125 

120 in a minute, while the heart's action is equable and of corre- 
sponding vigor. While this condition of things lasts the case is 
seldom one of danger. Indeed, with few exceptions, the state of 
the pulse and heart is throughout the most reliable guide we have 
in typhus. Some favorable, but very exceptional, cases will be 
met with from time to time, in which the characters of the heart 
and pulse are perfectly equable and uniform throughout to the 
end of the fever. It is more common, however, to find a certain 
amount of failure in the circulation, as a prominent feature in the 
case, after the seventh or eighth day. The first indication which 
presents itself is that of a slight increase in frequency, the pulse 
rising from five to ten beats in a minute. 

This increase in the rate of the pulse is very frequently mis- 
interpreted; quick pulse is supposed to indicate smart fever, and 
smart fever acute inflammation; while in its turn inflammation 
supposes the necessity for depletory measures. And yet nothing 
can be more entirely erroneous; if the pulse in typhus be care- 
fully observed, it will be soon learned that as it gains in frequency 
it loses in volume, in resiliency, and in the completeness of the 
arterial wave under every aspect. There is also, in most cases, 
at the same time a small but sensible diminution of the general 
nervous energy of the patient. The extremes of the condition 
under consideration are when the pulse rises to 135 or 140, or 
even more, with a rapid and feeble tic-tac, tic-tac action of the 
heart. 

There is no class of cases in which the patient succumbs so 
rapidly, and, to the inexperienced physician, so entirely unex- 
pectedly, as in the circumstances we are now considering. The 
patient literally slips through the fingers of his doctor, almost 
before the latter has begun to suspect that there is any danger 
whatever; there has been no delirium, no cough, and no local or 
general symptoms of any kind sufficient to give the alarm. 

In the next variety of cases we have often a very forcible con- 
trast between the pulse-rate and volume, and the sounds and 
impulses of the heart. In the first variety of cases it will be 
noted that, as the pulse becomes quick and weak, the cardiac 
impulse increases in force, till ultimately the ventricles are found 
acting with great violence, and at last in a perfectly tumultuous 
manner. The force of the heart's contractions is often such as to 
be the source of much distress to the patient himself, shaking the 



126 TYPHUS. 

precordial region and the whole of the chest in a most singular 
manner: if the hand of the physician be placed over the precor- 
dial region, in these cases, he will easily realize what has been 
well designated, as the sledge-hammer pulsation of the heart; the 
jarring shock of the heart against the hand is painfully strong. 
That this is not a perfect contraction of the ventricles is shown 
by the weakness of the pulse in vessels near the centre of the 
circulation, such as the carotids. This condition of sledge-ham- 
mer heart and feeble radial pulse, 130 to 140 per minute, is often 
attended by great prostration of the nervous and muscular ener- 
gies, and the patient sinks outright without the slightest attempt 
at rallying. It is worthy of note that this train of morbid actions 
is often within the control of stimulants, while, on the other hand, 
depletory measures aggravate all the symptoms. Many of these 
cases are likewise attended by profuse and uncontrollable diapho- 
resis, which is an additional omen of bad augury. The practical 
deduction from what we have here defined, is, that in all cases in 
which the pulse rises above 120, stimulants must be administered 
and their effects carefully watched. 

A very singular want of uniformity in the force and. volume 
of the arterial pulse in different parts of the system will be noted 
in certain cases of typhus ; thus we will sometimes find the 
carotids acting with great violence, while the radial pulse is not 
sensibly disturbed. In other cases the temporal vessels will be 
those acting with excessive force ; but the most singular state is 
that in which, with moderate force and volume of the heart and 
radial pulse, the abdominal aorta, or the iliac arteries, or both, are 
felt to act with inordinate vigor. There is nothing more striking 
in the course of fever than the manner in which the several parts 
of the vascular system seem to act with almost perfect independ- 
ence of each other. 

Observations of this kind, which the practical physician can 
verify for himself in the course of fever, tend to show that the 
heart is not the sole agent in maintaining the circulation ; if it 
were, we never could have the combination of a feeble heart and 
an excited and strongly acting abdominal aorta. 

A total extinction of the pulse is met with only in extreme 
cases of typhus, or in the period of profound collapse which pre- 
cedes death. The pulse is, however, often so weak, thready, and 
"shabby," that it requires great experience and delicacy of touch 



LESIONS OF THE HEART IN TYPHUS. 127 

to be able to feel it at all in some cases. The highest rate which 
the pulse reaches may be stated to be between 140 and 150; it 
has been said to reach much higher than this, but I cannot verify 
the observation from personal experience. Pulse-rate must be 
regarded as a very important indication in the progress of any 
case of fever ; if, as before stated, it passes 120, we are warranted 
in regarding it as a symptom of danger. Irregularity in its beats, 
inequality in volume, or intermission ; are likewise unfavorable 
indications. I have known an irregularity by intermission of 
every tenth beat to be the only unfavorable sign for days in cases 
which subsequently proved fatal. On the other hand, we will 
find when the case is about to mend, that the first favorable indi- 
cation is to be got from the pulse. In the sections on treatment 
this subject will be more fully entered into. It will be sufficient 
to state here that we observe in practice two opposite effects on 
the circulation as the result of treatment ; in one set of cases the 
circulation is quickened and excited, and all the patient's symp- 
toms are rendered worse by the exhibition of stimulants ; such 
cases very generally prove fatal. In the other class of cases 
stimulants lower the frequency of the pulse, and at the same time 
increase its volume ; the patient becomes tranquillized, and all 
the other symptoms improve: such cases generally recover, how- 
ever unfavorable they may have looked at first. 

The state of the circulation in fever, however, can only be 
rightly judged of when the heart and pulse are both examined 
with care from day to day ; we have seen that in fever we cannot 
argue from the state of the one to the state of the other. The 
examination of the heart from day to day in typhus forms an 
indispensable part of the duties of the physician. The impulse 
as well as the sounds of the organ must be carefully explored at 
each visit, and the slightest changes noted. 

It is not uncommon to find that when the general nervous 
energies become depressed by the seventh or eighth day, the im- 
pulse of the heart undergoes a slight diminution in force ; the 
hand must be carefully placed in uniform apposition with the 
precordial region to detect the extent and force of the heart's 
action. Dr. Stokes first called attention to a singular class of 
observations, by which he has shown that in many cases of typhus 
the impulse of the heart becomes less and less from day to day, 
and this has been known to proceed to such an extent that finally 



128 TYPHUS. 

the heart has been found acting without any appreciable impulse 
whatever; in other words, the contraction of the ventricles was 
so feeble that it produced no reaction on the thoracic walls which 
cover it, and no touch, however delicate, could detect any motion 
of the heart against the ribs. It has been observed in this class 
of cases that the heart has acted for days together without pro- 
ducing sensible impulse against the side. As might be expected, 
diminution in the cardiac impulse is generally attended with a 
diminution of the first sound of the heart; we notice from day 
to day that the first sound is diminishing in loudness and dura- 
tion ; it gradually becomes fainter and fainter, and from being 
more than twice as long as the second sound, it becomes of the 
same length and also approaches it in tone. In extreme cases 
this diminution progresses until a total extinction of the first 
sound is effected, and then we have the extraordinary pheno- 
menon of the heart acting without any appreciable impulse, and 
with only one sound, that sound being the second or valvular 
sound of the heart. We may have this state of things continu- 
ing for some days, and yet the case is not to be despaired of. 

In those instances in which the first sound is not wholly ex- 
tinguished, but becomes feeble and short like the second, and the 
action of the organ is at the same time rapid, i. e. between 130 
and 140, a singular and striking resemblance is produced to the 
action of the heart of the foetus in utero. This condition has 
been very aptly termed the foetal state of the heart in typhus, and 
the resemblance is sufficiently obvious. Of the prodution of this 
state of the heart in typhus I can have no manner of doubt what- 
ever, as I have myself verified the condition over and over again 
in well-marked cases of typhus fever. I have noted the gradual 
diminution in the force and duration of the first sound in the 
progress of many a well-marked case to the final extinction of it, 
and I have again traced its gradual reappearance, and, as it were, 
the growth and development of the first cardiac sound and im- 
pulse up to the complete re-establishment of the normal cardiac 
action as the case progressed towards recovery. 

In the pathological anatomy of the heart in typhus, we find the 
best explanation of these phenomena : the most important abnor- 
mal change which we observe in the heart's texture consists in a 
flabbiness, softness, and almost putrid condition of the muscular 
structure. The organ lies collapsed in the pericardium, and is 



SOFTENING OF THE HEART IN TYPHUS. 129 

often broken through in the attempt to remove it from the 
body. When placed upon the table, the ventricles lose their 
plumpness and convex form ; if the organ be held up by the 
apex, the auricles and the rest of the ventricles fall in a soft 
confused mass over the hand ; slight pressure breaks through the 
texture of the organ, and the finger passes through its walls on 
the slightest pressure ; the muscular tissue is in fact manifestly 
softened and partly disintegrated, and it has a fishy, gluey, or 
sizy appearance. Much controversy arose at one time as to the 
nature of this change; some supposed it to be the result of in- 
flammation, others regarded it as caused by an infiltration of the 
massa t-yphosa, or typhous matter : its true nature is not yet well 
defined; it is not improbable, however, that it partakes of the 
nature of an acute fatty degeneration. Others have repeatedly 
admitted the existence of a diseased state of the voluntary muscles 
in typhus ; Laennec speaks of a gluey or fishy state of the muscles, 
supposed to have some connection with other phenomena of pu- 
trescence in the so-called putrid fevers. 

Louis states, as the result of extensive observations, that he 
has found the muscular texture of the heart in typhus of less con- 
sistence than natural in a considerable number of cases ; in some 
instances the change was very marked, the heart being so flaccid 
that it had no precise form, but, like a wet cloth, fell into any 
shape according to the way it was placed on the table; it had little 
or no power of cohesion, and it was easily broken through. Louis 
describes the internal surface of the auricles and ventricles as 
being of a deep violet-red color, which he ascribes to imbibition 
of blood, and not to the effects of inflammation ; this latter agenc}' 
he for several reasons excludes from amongst the possible causes 
of the changes of the heart in question. 

Louis's results further show that the frequency and extent of 
the softening of the heart's texture are in proportion to the early 
fatality of the disease; the heart being found softened in nearly 
half of those patients who die between the eighth and twentieth 
day of the fever. He regards the change in the heart as analo- 
gous to that of the liver and spleen in typhus. Stokes makes the 
observation, that in those cases in which there was marked soften- 
ing of the heart the patients exhibited during life a dark-colored 
and abundant petechial eruption, while the mouth was covered 



130 TYPHUS. 

with sordes, and the body exhaled the peculiar fetor of typhus, ex- 
treme prostration and stupor being also generally present. 

There is no ground for supposing that the state of the heart 
now under consideration is the result of putrefactive decompo- 
sition ; amongst other reasons against this view, it may be stated 
that the change is not always general throughout the heart, as it 
would be if it resulted from decomposition ; it is often confined to 
the left ventricle, and it is usually more developed in this situation 
even when the other parts of the heart are affected. It is not to 
be expected that every epidemic of typhus fever will present the 
same proportion of cases in which the heart becomes affected, and 
in every epidemic numbers of cases occur in which there is no 
evidence whatever during life or after death that the heart has 
been implicated in any manner. 

In some few rare instances a systolic murmur, occasionally of 
a musical character, has been noticed. But it is in certain cases 
of non-maculated fever, occurring in connection with or at the 
end of typhus epidemics, that the most marked form of murmur 
has been observed in the heart. The cases in which these obser- 
vations were made occurred in the Meath Hospital, in the city of 
Dublin, and were noted by Dr. Heslop, now of Birmingham, and 
the author. They were cases of non-maculated relapsing fever, 
and it was in the first relapse that a murmur was observed to 
attend the first sound of the heart ; the singular peculiarity of 
this murmur was, that when the patient sat up in bed it dimin- 
ished so as to be scarcely perceptible. It was further noted that 
the murmur disappeared as the patient progressed in convales- 
cence. In some instances, a prolongation of the first sound of 
the heart to nearly double its ordinary duration, but without 
murmur, was remarked. 

SECONDARY AFFECTIONS OF THE RESPIRATORY ORGAN'S. 

The principal affections of the chest in the typhus fever of this 
country are bronchitis and pneumonia. 

Bronchitis forms at once the most frequent and the most for- 
midable of the secondary lesions of the typhus of Ireland; it has 
been, in fact, an all but constant affection in every case of typhus 
during the epidemics of recent times. So much has this been the 



SECONDARY BRONCHIAL AFFECTIONS IN TYPHUS. 131 

case that, as before observed, the term "catarrhal typhus" has 
become a familiar designation with many practitioners. 

In most of the chest affections in typhus, there is a remarkable 
and insidious latency of the early symptoms. Again, we often 
find that the bronchitis and pneumonia of typhus pass suddenly 
into a fully developed condition, and that there is, as it were, an 
abortion or suppression of the ordinary first and second stages. 
Thus it will sometimes happen that the first indication we get of 
the presence of inflammation of the lung, in a case of fever sup- 
posed to be progressing favorably, is the existence of extensive 
dulness on percussion over a large extent of surface, or an intense 
muco-crepitating rale pervading both lungs, anteriorly and pos- 
teriorly. 

It is unnecessary for us here to recapitulate the signs and 
symptoms by which ordinary bronchitis or pneumonia is to be 
recognized. Cough, dyspnoea, sonorous, sibilant, and subse- 
quently soft mucous rales (when present), indicate bronchitis in 
typhus, as they do under ordinary circumstances. But in typhus 
the practical difficulty arises from this circumstance, that the 
cough is slight and wholly disproportionate to the amount of 
bronchial lesion present; the same is to be said of the symptom 
of dyspnoea ; while the pyrexial reaction is not such as to show 
anything remarkable in the case. For these reasons the first 
periods of the disease pass by without any suspicion being awak- 
ened on the part of the medical attendant, unless he has been put 
on his guard by previous experience, or by a sound education in 
the pathology of typhus. Unless the patient's chest be daily ex- 
amined with the stethoscope, this formidable lesion will in a couple 
of days have made such headway as to baffle the best directed 
efforts of the physician. Many a patient is thus irrecoverably lost, 
almost before his attendant suspects that there is anything unusual 
in the case. 

To the experienced physician, the approach of an important 
thoracic lesion is often indicated by a slight increase in the general 
pyrexial excitement of his patient's system ; the pulse is observed 
to be a little harder and quicker, and the respiration to be a little 
shorter and more hurried. Cough, with considerable dyspnoea 
and subsequently expectoration, and other manifest symptoms of 
bronchitis, are no doubt often present to such an extent as at 
once to declare the nature of the affection. But though this class 



132 TYPHUS. 

of cases is occasionally fatal, it is not from them that most danger 
is to be apprehended. They admit of being diagnosed early, and 
generally yield to appropriate remedies when timely administered. 

The most formidable variety of bronchitis is that which, com- 
mencing insidiously, and being latent as far as symptoms are 
concerned, quickly engages a large extent of the bronchial mu- 
cuous membrane in one or both lungs. There is little or no 
cough, and the expectoration is inconsiderable ; while there is no 
dyspnoea or other symptom to attract attention to the patient's 
chest. Supposing a case of this kind to be neglected for a couple 
of days, or rather overlooked in consequence of the patient's chest 
not being examined daily with the stethoscope, the bronchial 
affection, latent and unnoticed hitherto, suddenly reaches an 
alarming height, the case is in imminent danger, and in a large 
majority of such instances no efforts will save the patient's life. 
What happens in these cases is this : the bronchitis was for the 
first two or three clays confined to the primary and secondary 
tubes ; the tendency of the disease is, however, to spread along 
the mucous surface of the bronchi, and the moment the tertiary 
and ultimate ramifications of these tubes become invaded, the 
symptoms assume an alarming character. This is fully explained 
by the condition found to exist on post-mortem examination. 

On opening the thorax in such cases the lungs do not fully 
collapse, a certain quantity of air being mechanically imprisoned 
in the smaller bronchial ramifications and air-cells. On slitting 
up the trachea and bronchi, these tubes are found filled with a 
viscid, glairy secretion, which extends down to the minute air- 
cells, filling the whole bronchial tree as completely as if forcibly 
injected from a syringe. The mucous membrane is at the same 
time found thick, soft, and somewhat of a pulpy consistence ; the 
color of the mucous surface is likewise altered, it is usually of a 
deep reddish tint. The superficial epithelium can be scraped off 
in quantity, exposing a condition of intense vascular injection 
beneath, with great turgescence of the basement membrane. 
These conditions imply a considerable diminution in the calibre 
of the entire bronchial tree, together with a superabundant se- 
cretion of viscid mucus. But it is probable that there is another 
condition superadded during life — namely, that of a somewhat 
paralytic state of the bronchial muscles; it is now well known 
that the longitudinal and circular muscular fibres, which constitute 



CAPILLARY BRONCHITIS IN TYPHUS. 133 

a distinct coat of the bronchial tubes, play a most important part 
in the expiratory and expectorant functions. In the low state of 
innervation which characterizes typhus, these muscular fibres of 
the bronchi, the so-called muscles of Reisseissen, become paralytic. 
The bronchi are thus unable to throw off the secretion poured 
into them in excess from the softened and highly vascular mucous 
surface ; the secretion thus goes on accumulating in the surcharged 
bronchi, and the patient finally dies a mechanical death. Under 
ordinary circumstances, even a very small amount of secretion 
poured out into any part of the bronchi acts as an irritant on the 
muscles of Reisseissen, which are thrown into active contraction, 
evinced by forcible expiratory and expectorant efforts, realized to 
our ordinary senses by the phenomenon we denominate cough, 
and by the ejection of sputa. As will be presently considered, 
our main indication for rational treatment in these cases consists 
in the use of remedies which act by irritating and stimulating the 
paralyzed bronchi to throw off the secretion with which they are 
overloaded. 

To return to the consideration of the symptoms during life : 
we find that when the minute bronchi become affected, dyspnoea, 
hurried breathing, lividity of the face, and general oppression 
are apparent. The respiration rises to 40, 50, or even 60 
per minute. There is a corresponding alteration in the pulse, 
which goes up to 130, 140, or in extreme cases, 160. Muco- 
crepitating rale is now audible in all parts of the chest, and 
towards the close of the case a loud rattle is produced in the 
bronchi and trachea, audible at some distance from the patient's 
bed. Notwithstanding the superabundant secretion which takes 
place into the bronchi, expectoration is either very scanty or 
altogether suppressed. It very frequently happens that there is 
profuse and persistent sweat over the whole body at this period ; 
this is, in my experience, only an additional symptom of fatal 
augury. 

In considering the treatment of the catarrhal affections of 
typhus, the golden rule is to anticipate them if possible. If they 
are allowed to steal a march on us, even for a single day, their 
progress is so rapid, and their effects are so overwhelming on a 
patient already prostrated by other influences, that there is but 
little chance of saving life in many instances. It cannot be too 
strongly impressed on the student and junior physician, that to 



131 TYPHUS. 

examine the chest and all other organs carefully from day to day 
is a part of his duty which he cannot neglect without incurring 
the gravest responsibilities. He must remember that he is not 
to wait for cough, pain in the chest ; or any of the ordinary signs 
and symptoms of bronchitis; when such signs and symptoms 
become manifest, the patient is too often so far gone that his case 
is utterly hopeless. When, therefore, the stethoscope reveals 
the presence of sonorous or sibilant rales in any considerable 
portion of either lung, it is high time to take the alarm, and to 
direct prompt measures of treatment to the chest. The locality 
in which rales, whether dry or moist, first make their appearance 
may enable us to form some estimate of the probable gravity of 
the case ; thus, rales commencing in the anterior and upper part 
of the chest indicate that the bronchial affection will in all pro- 
bability be one of great severity. 

Depletion is the first means which will suggest itself to the 
mind of most practitioners, but experience shows us that we 
have little to expect from it ; venesection is, I hold, simply out 
of the question, but local depletion may in some cases be resorted 
to. The rapidity with which the bronchial affection invades both 
lungs throughout a large part of their extent, precludes the use 
of local abstraction of blood by cupping or leeching in most cases. 
When, however, the bronchitis is found limited to any defined 
portion of lung substance, the wet cupping-glass may be used 
with effect, and from four to six, or, in extreme cases, eight ounces 
of blood abstracted. Dry cupping is a means of much more gene- 
ral application, and is of great utility in many cases, in which, 
owing to the extreme prostration of the patient, we dare not 
abstract a single ounce of blood from the body. The chest may 
be extensively dry-cupped, both before and behind, and this is 
often attended with great relief to the patient; this operation 
must be rapidly and carefully done, and with as little exposure 
and fatigue to the patient as possible. 

Counter-irritation offers another and effective means for dealing 
with cases of this kind. Eubefacient liniments, sinapisms, and 
the ordinary emplastrum lyttae may be used, as circumstances 
seem to warrant. As a general rule, vesication is to be employed 
immediately over the part principally affected; but, unless for 
special reasons, I think it better that we should avoid blisters to 
the posterior parts of the chest in typhus, as there is often a low 



TREATMENT OF TYPHOID BRONCHITIS. 135 

action set up in the blistered surfaces, which leads to the forma- 
tion of troublesome bedsores when blisters are applied to depend- 
ent parts, or those subjected to pressure. In most cases a blister, 
six to eight inches square, applied over the sternum, will answer 
all purposes; it seems to act in two principal ways, first, by deri- 
vation and depletion, in consequence of the serous fluid which it 
abstracts from the blood; and secondly, as an irritant and stimu- 
lant to the paralyzed nerves of respiration. In some cases, where 
the prostration of the system is extreme, vesication cannot be 
effected by the common blister, and it will be necessary to have 
recourse to acetum lyttae, which may be lightly brushed over the 
surface, when it rapidly produces extensive vesication in most 
instances ; but I have known cases in which even this applica- 
tion failed, owing to the utter want of reaction in the patient's 
system, though death did not ensue until four and twenty hours 
subsequently. 

Tartar emetic will seem an obvious remedy in this as in other 
forms of bronchitis ; but there is one fatal objection to its use, 
namely, the already depressed condition of the circulation. We 
cannot, therefore, include it in the articles of the materia medica 
likely to prove useful in typhous bronchitis. Mercury given to 
salivation is likewise inapplicable as a remedy in these cases. 
But in the form of hydrargyrum cum cret& it may be used in 
combination with hippo and squill, to produce an alterative effect 
and promote expectoration. Thus from one to two grains of 
hydrargyrum cum creta may be given with half a grain of hippo 
and a quarter of a grain of squill, in the form of pill or powder, 
every second or third hour. 

Such means as those now indicated are entitled to a fair trial 
at the outset of the affection. But if no good result be manifest 
in from twelve to twenty-four hours, we must not lose valuable 
time by further delay, and more active medicines are now called 
for. The decoction of polygala seneka ; with carbonate of ammo- 
nia (half a drachm to two drachms), tincture of squill, and hippo 
wine, constitute a remedy of great value and efficacy in numerous 
cases. The Virginian snakeroot is in itself a powerful stimulant 
and expectorant, and these latter effects of the drug are much 
enhanced by the addition of ammonia. There is only one objec- 
tion to this latter remedy, namely, its tendency to run off by the 
bowels in many cases; if it produce this effect we must of course 



136 TYPHUS. 

abaDdon its use, and trust to the action of diffusible stimuli in 
other forms, as ether, brandy, wine, punch, &c. Cases will occur 
in which all these therapeutical means are tried in combination, 
and in which no relief is produced to the urgent symptoms of 
thoracic oppression and mechanical filling up of the bronchial 
tubes. Under these circumstances the case is in extremis, as in- 
dicated by the audible rattle in the bronchi, and the lividity and 
prostration of the patient. In such a predicament we have but 
one or two remedies more to fall back upon, ere we abandon the 
case as hopeless. A mustard emetic will be sometimes found to 
act as a charm in unloading the bronchial system. It seems to 
act by a refiex agency through the gastric filaments of the vagi 
upon the pulmonic plexuses, stimulating the semi-paralyzed bron- 
chial muscles, promoting copious expectoration, and, by allowing 
free ingress of air, causing renewed oxidation of the blood, and 
general stimulation of the system. Over and over again it occurs 
that the timely exhibition of a mustard emetic not only saves a 
patient from the immediate danger of impending suffocation, but 
becomes the turning point to convalescence with an effect that is 
quite surprising. 

Turpentine constitutes a remedy of extraordinary efficacy in 
many cases of typhus bronchitis, when almost at the last gasp. 
In doses of from fifteen to twenty drops, spirit of turpentine is a 
powerful expectorant; in extreme cases it may be employed in 
drachm doses. It may be given in almond mixture, with the addi- 
tion of a drachm or two of chloric ether to the eight-ounce bottle. 
The valuable effects of turpentine in this class of cases are by no 
means sufficiently known ; it seems to act as a specific irritant 
upon the bronchial membrane, inducing cough and expulsive 
contraction of the semi-paralytic circular and longitudinal mus- 
cular fibres. After the third or fourth dose, a patient in whom 
passive bronchial effusion has been rapidly accumulating, and in 
whom the inertness of the bronchial tree is shown by the absence 
of cough, or any attempt to expectorate, will begin to throw off 
by cough and expectoration large quantities of viscid and frothy 
mucus. The effects produced in a few hours in these cases is 
perfectly astonishing. With the readmission of air into the lungs 
now permitted by the evacuation of the viscid contents of the 
bronchi, the blood is again rapidly and completely oxygenated, 
and the system of the patient invigorated and refreshed. This is 



PNEUMONIA IN TYPHUS. 137 

a new triumph for turpentine, hardly anticipated by the author 
of the " Currus triumphalis e Terebintho." 

Pneumonia. — Next to bronchitis, pneumonia is perhaps the 
most formidable secondary lesion which we meet with in typhus. 
Though the catarrhal affection exists commonly enough without 
consolidation of the lung tissue, it is extremely rare to find pneu- 
monia occurring in typhus without an accompanying bronchitis 
of greater or less extent. Indeed, one of the most formidable 
aspects in which we have to consider this form of pneumonia, is 
in connection with capillary bronchitis invading one or both 
lungs. The pneumonia occurring in typhus is distinguished 
from the ordinary sthenic inflammation of the lung by the follow- 
ing characters — namely, the low prostration of the patient ; the 
sudden and silent invasion of the disease, with a total absence of 
the usual premonitory symptoms ; and the more or less complete 
suppression or abortion of the usual first stages of this affection 
as presented in a healthy system. For example, we find the lung 
suddenly passing into a condition of complete consolidation, with 
dulness on percussion, bronchial respiration, and bronchophony. 
It is also to be observed that the disease first implicates those 
parts of the lung which ordinarily escape, or are last affected in 
sthenic pneumonia ; in other words, in typhus pneumonia the 
upper and anterior parts of the lung are engaged in preference 
to the lower and posterior. The disease likewise exhibits a 
marked tendency to early fatal issue ; and it will be observed 
throughout the course of the case, that the sputa are in exces- 
sively small quantity or altogether suppressed; the cough is short 
and dry, and the pain in the lung is inconsiderable. Complete 
dulness on percussion is early developed, and persistent through- 
out, except in those singular cases in which it is replaced by a 
suddenly developed tympanitic sound. This is one of the most 
singular phenomena we are acquainted with in acoustics of 
thoracic disease. In a situation in which we have determined 
the existence of complete and absolute dulness on a given day, 
we find on the next visit that the dulness is replaced by a sound 
of tympanitic character. When a case of this kind is seen for 
the first time, it will be supposed that pneumo- thorax has been 
suddenly developed: but on carefully analyzing the percussion 
sound, it is observed to be one not of tympanitic clearness but of 
tympanitic dulness. This seems a paradoxical expression, but 



138 TYPHUS. 

when the sound in question is heard, it will be found that it is 
well described by the term employed. It conveys the idea of a 
deeply seated resonance being conveyed through a superficial 
layer of solid texture, the latter causing the dull sound, while the 
former gives rise to the tympanitic resonance. Many explana- 
tions have been offered for this singular phenomenon. I believe 
it to be caused by a mass of densely solidified lung in close appo- 
sition, on the one hand, with either bronchus, and on the other 
with the wall of the chest, and thus conveying to the surface 
directly the clear and resonant percussion notes developed by 
the vibrations of the air in the bronchi. 

When the lungs reach the condition of complete antero-superior 
dulness, the case must be looked upon as one of great severity. 
In the low condition in which the patient already is, the pneu- 
monic inflammation is in itself sufficient to turn the scale and 
lead to a fatal issue. The fatal event often comes with great sur- 
prise upon those, whose notions of pathology are so mechanical 
that they expect the general symptoms of a case to be always in 
proportion to the amount of local disease. To such persons it is 
entirely unintelligible that a patient shall die of an inflamma- 
tion of the lung, which engages not more than a hand's breadth 
of the organ. And yet this is often the case in the pneumonia 
of typhus. The occurrence of pulmonic inflammation should, 
therefore, in all cases make us most guarded in prognosis, and 
active while judicious in treatment, knowing as we do that many 
of these cases sink with extraordinary rapidity. But we have 
other dangers to apprehend in cases of this kind. The bronchitis 
of typhus is often, even in its most aggravated and fatal forms, an 
isolated lesion, and the only one from which the patient suffers. 
This is not so with the pneumonic inflammation of the lung in 
typhus, which is almost always associated with a certain amount 
of bronchitis. We have already seen what dangers are to be 
apprehended from typhoid bronchitis ; it is still more to be feared 
when it occurs in connection with pneumonia. 

In the low typhoid inflammation of the lung, even when not 
fatal in the primary periods, we have still further dangers to 
apprehend. Thus we find sudden purulent infiltration, abscesses 
or gangrene suddenly developed in a lung which has been the 
seat of typhoid consolidation. When the organ passes into the 
stage of purulent infiltration, we find a slight diminution in the 



TREATMENT OF TYPHOID PNEUMONIA. 139 

duloess on percussion, with large muco-crepitating rale and 
purulent expectoration. Abscess is indicated by the sudden 
development of the signs of cavity, gargouillement or gurgling, 
and copious purulent, sometimes fetid, expectoration. Gangrene 
of the lung is indicated by the usual signs of this affection, and 
the horribly fetid and unmistakable odor which accompanies it. 
As these conditions of the lung come under the general rules 
of thoracic diagnosis, we need not consider them more in detail 
in this place. 

The treatment of typhoid pneumonia is, on the whole, very 
much that of typhoid bronchitis ; general bleeding is out of the 
question, and even local abstraction of blood must be employed 
with caution. Cupping, to the extent of six to eight ounces, is 
in many cases useful, and in some instances it may be repeated 
with advantage. Dry-cupping is likewise beneficial, but is, I 
think, not so efficacious in pneumonia as in bronchitis. Vesica- 
tion, with the emplastrum or acetum lyttae as in bronchitis, may 
be employed. In selecting a general plan of treatment in typhoid 
pneumonia, we are generally compelled to reject altogether the 
use of tartar emetic, from the low state of the patient's system. 
Mercury is then the only alternative, and if its use be determined 
on, we must endeavor to get the patient under its influence as 
rapidly as possible. This we can sometimes effect within a day 
and night by grain doses of calomel, properly masked with opium, 
every hour. Others prefer larger doses at the outset, and two or 
three grain doses in the form of pill every third or fourth hour. 
Mercurial inunction in the groin and axillae, and mercurial dress- 
ings to any blistered surfaces which exist, will promote the 
specific action of this drug. Hydrargyrum cum creta (two to 
three grains) with hippo and squill (half a grain of each) is much 
recommended by some practitioners, and is certainly useful in the 
early stages of those cases in which secretion is suspended. It 
is never to be forgotton, however, that these cases require free 
stimulation, which must always form a prominent item in the 
treatment. The pulse must be carefully watched, and when it 
shows the slightest tendency to rise in frequency, while it dimi- 
nishes in volume, it is an unmistakable indication for the use of 
ammonia, wine, or brandy, or all three combined. It will often 
be noticed that the pulse rises steadily as the pneumonic affection 
advances, till it reaches 140, 150, or even more, per minute, being 



14:0 TYPHUS. 

at the same time excessively feeble, and readily extinguished on 
the slightest pressure with the finger. 

In singular contrast with the state of the pulse, violent thump- 
ing action of the heart is often to be observed in these cases; this 
is perceptible by the hand placed over the precordial region, and 
in some instances, where the solidification of the lung occurs at 
the right side, the shock of the heart may be felt and heard with 
great force in the right axilla. ZSTo combination of signs can pos- 
sibly be observed worse than the following — namely, solidified 
lung on the tenth or twelfth day of typhus, with a pulse at 140, 
or it may be as high as 150, and weak, thready, and shabby, while 
the heart is pounding with apparently violent efforts — but we 
know incomplete contraction of its ventricles. Till a decided 
impression has been made on the pulse and heart, the case must 
be pronounced one of most imminent danger. "When profuse 
sweat is superadded to these symptoms. I know of almost nothing 
which warrants us in indulging a single hope of the case. Coun- 
ter-irritants, mercurials, and stimulants, singly or in combination, 
will often be found to fail in many of these cases, especially 
whenever bronchitis is combined with pneumonia or supervenes 
upon it. Under these circumstances, turpentine must be had 
recourse to, and occasionally its effects are almost magical. It 
may be given in fifteen, twenty, or thirty-drop doses, or in ex- 
treme cases, in teaspoonfuls every hour till cough and expectora- 
tion are produced. The tolerance of stimulants in this class of 
affections is something quite remarkable. Persons of habitually 
temperate habits, and even females, will, when in typhus, take 
with impunity, in the course of a very few hours, a quantity of 
wine, punch, or raw brandy, which in the state of health would 
make them stupidly and hopelessly intoxicated ; and yet while in 
the typhoid state, the most liberal amount of stimulants seems to 
be expended in keeping the system at par. Without stimulants 
the patient sinks visibly into low muttering delirium, while the 
pulse is up to 140. Under the influence of stimulants, the pulse 
in a favorable case will be observed to fall from hour to hour till 
it reaches the comparatively safe rate of 110 or 120; for with 
moderate volume, fair tension and equable and uniform cardiac 
action, we may consider a pulse of 120 as tolerably safe and re- 
liable. The faculties all this time are becoming more and more 
clear, and, singular as it may seem, the patient is becoming more 



PLEURITIS IN TYPHUS. 141 

and more rational and coherent the deeper he drinks, which, it is 
needless to say, is the opposite to what would occur if he were in 
the state of health. 

It is an observation founded on experience, and one full of 
practical import, that on the whole the free use of stimulants in 
typhus is far more successful in saving life amongst persons who 
have been previously of abstemious habits, than in those who 
have been addicted to intemperance. In this latter class of cases, 
likewise, stimulants are not infrequently badly tolerated by the 
system, and instead of tranquillizing the patient, cause nervous 
excitement and occasionally violent delirium. For these reasons 
we are sometimes obliged to throw away our last and best chance 
of saving the patient, when all other means have failed. 

We must always have in view at the outset of thoracic lesions 
in typhus, that we have to do with a silent and insidious enemy, 
who displays his forces suddenly, and when we are least prepared 
for the attack. We have also to remember that an amount of 
disease, which, under other circumstances, would make but little 
impression on the patient's system, may now prostrate it com- 
pletely and fatally. It must therefore be ever a leading indica- 
tion in the treatment of this class of affections, not only to avoid 
lowering the system by depletory or exhaustive measures, but to 
anticipate and prevent that sinking, which experience shows us 
to be the inevitable concomitant of the typhous state. We must 
therefore fortify the system, while we endeavor to cure the gene- 
ral as well as the local diseases. 

Typhoid Pleuritis. — This is a comparatively rare affection, and 
it is somewhat remarkable that pleural affections are much more 
frequent as secondary lesions of the typhoid than of the typhus 
fevers. When pleuritis occurs in connection with typhus, it is 
seldom if ever attended by any of the usual signs of the disease. 
It wants the sharp lancinating pains, dyspnoea, and short hurried 
breathing, so characteristic of ordinary pleuritis. The pleural 
affection in typhus is subacute, and, as it were, passive ; it ad- 
vances insidiously, and is often not discovered till there is a con- 
siderable amount of effusion, with dulness on percussion, and 
absence of respiration. The friction signs of ordinary pleuritis 
are hardly ever to be expected in the typhoid disease. 

The treatment of this affection is subordinate to that of the 
general fever; counter-irritation must be our main resource, and 



142 TYPHUS. 

we have no other means of attacking the disease during the 
persistence of the febrile state. At a subsequent period, if the 
pleural affection assumes the condition of chronic empyema, it 
must be treated accordingly. Under these circumstances mercu- 
rial alteratives, and tonics combined with iodine and the iodides, 
internally and externally, will be proper. But we must not here 
anticipate what we shall have to say in a future chapter about 
the sequelas of fever. 

SECONDARY LESIONS OF THE ALIMENTARY TRACT. 

We have already considered the state of the tongue (see p. 107). 
The more important phenomena connected with the stomach have 
also been treated of. It is worthy of note, that in some epidemics 
of pure typhus there is a far greater preponderance of cases in 
which the intestinal mucous surface is affected than in others. 
When speaking of the bronchial affections, we saw how great 
was the preponderance of that form of secondary lesion in most 
of the Irish epidemics. But gastric and intestinal symptoms 
appear to exhibit the preponderance in other epidemics. When 
the stomach is much engaged, it is not unusual to designate the 
disease as " gastric fever;" and again, when affections of the lungs 
and stomach prevail in the same epidemic, it becomes known in 
popular medical language as " gastro-catarrhal typhus." 

Lesions of the intestines in typhus. — The intestinal lesions of 
typhus are of a much less complicated kind than those of the 
fever, now generally known by the distinguishing name of typhoid 
or enteric fever. In the former, the secondary lesions of the 
intestine may be said to be occasional and intercurrent, but to 
have no necessary connection whatever with the disease in its 
pure form. In the latter, that is to say, the typhoid fever, a 
series of pathological changes, of well defined and almost specific 
character, is developed in the course of the disease in a particular 
anatomical situation — namely, the follicular apparatus of the 
small intestines — and this with such constancy, as shown by the 
results of numerous investigations, that it is impossible to resist 
the conclusion, that the lesion of the intestine is part and parcel 
of the disease, if not the cause of some of its principal phe- 
nomena. 

After a now extended series of inquiries into the pathology of 



INTESTINAL LESIONS OF TYPHOID AND TYPHUS. 143 

typhus fever, properly so called, the following are the principal 
anatomical states of the intestinal mucous surface which I believe 
usually attend the disease : — 

(a.) A state of more or less extensive stellate and ramiform 
vascularity, involving part or, whole of the jejunum or ileum, or 
of both these intestines. This state is frequently attended with 
bright pink vascularity, and villous turgescence of the mucous 
surface. The intestines are usually of moderate volume, and 
contain fluid fecal matter. Smart diarrhoea has usually been 
present during life, with more or less distinct signs of intestinal 
irritation. 

(b.) A condition of vascular turgescence, with dark purplish 
arborescent vascularity ; the intestines are usually distended with 
fetid gases, and the mucous surface, externally, is often of a dark 
purplish tint. These cases have been usually associated during 
life with diarrhoea and tympanitis sometimes developed to an 
inordinate extent, and constituting the most formidable symptom 
in the case. 

(c.) We occasionally meet with, here and there, throughout the 
ileum intestine, disseminated patches of stellate or arborescent 
vascularity, the surface having in these spots what is called a 
somewhat " angry" appearance. In some of these vascular 
patches, but not in all, there will be found on close inspection 
one or two small irregular superficial ulcerations. These ulcers 
seem to be altogether of accidental occurrence, and they certainly 
cannot be traced to any pathological connection with the symp- 
toms and progress of the case. These accidental spots of ulcer- 
ation, occurring now and then in a few isolated cases of typhus, 
are constantly appealed to as proofs of the identity of the patho- 
logical changes occurring in typhus and typhoid fevers. In 
connection with this subject, the following leading differences 
between the intestinal lesions of typhus, and those of typhoid, 
are worthy of note : — 

(1.) Ulcerations on the intestinal mucous surface in typhus are 
the exception, not the rule ; they certainly do not occur in five 
per cent, of the cases, as there is good reason to believe from the 
results of innumerable post-mortem examinations. 

(2.) Ulcerations of the mucous membrane of the small intestines 
are the rule in typhoid; they are not absent, in my opinion an$ 



144 TYPHUS. 

experience, in five per cent, of the cases of this fever in its pure 
form. 

(3.) The ulcerations of the mucous surface of the intestines, 
when they do occur in typhus, are few — three to four at most ; 
small, irregular, of uncertain seat and size, and usually quite 
superficial, and engaging the mucous surface only. It is also to 
be observed, that they are the only pathological condition of the 
kind present. 

(4.) In the ulcerations of the mucous surface of the intestines 
in typhoid, the pathological changes are of a well-defined charac- 
ter, pass through regular stages, occur in groups upon certain 
parts of the intestine, and occupy a specific anatomical situation ; 
and in the same case, it is common to find a regular and progres- 
sive series of pathological changes in the solitary and aggregate 
follicles. Thus, in one part of the intestine we may observe the 
follicles raised prominently above the surface by the infiltration 
of typhoid matter; and in other parts, softening and evacuation 
of this matter are going on ; while in. a still further stage, we find 
ulcers forming, which burrow deeply into the substance of the 
mucous membrane, expose the muscular coat, and may, and often 
do, finally end by penetrating the peritoneum itself. 

As the result of a very large experience in the pathology and 
pathological anatomy of both typhus and typhoid fevers ; I may 
be permitted to state it as my conviction, that any true follicular 
lesion of the intestine is as rare in the former (typhus fever) as it 
is common in the latter (typhoid fever). 

The most formidable affection presenting itself in the intestines 
in typhus, is that in which we have a congested, but at the same 
time weakened and atonic, state of the mucous membrane. Diar- 
rhoea, and more or less mucous irritation precede this condition ; 
and after a time we have meteorism or gaseous distension of the 
intestines; the abdomen swells to an enormous extent, and we 
find drum-like or tympanitic sound on percussion. The mechani- 
cal state of distension of the abdomen is a source of distress in 
two ways : firstly, from the accumulation of air in the stomach 
and intestines themselves; and next, from mechanical interference 
with the process of respiration, the descent of the diaphragm 
being impeded or prevented by the swollen state of the abdomen. 
We often find in connection with this state an irritation of the 
gastric membrane, such that the patient rejects a portion of almost 



TYMPANITIS IN TYPHUS. 145 

everything that is swallowed ; there is at the same time an irri- 
table action of the intestines, leading to constant diarrhoea, but 
with the discharge of only very small quantities of fluid matter. 
Under these circumstances, drink, food, and medicines, accumu- 
late in the intestinal tract, while gases are generated in excess. 
The distress caused by this accumulation of air and fluid is ex- 
treme ; the absorbent powers of the mucous surface seem for a 
time to be in abeyance ; while the muscular fibres are paralyzed, 
and the stomach and intestines seem incapable of freeing them- 
selves of their contents by peristaltic or anti-peristaltic action. 
There can be very little doubt that the state above described is 
one often brought on by the injudicious use of medicines, aliments, 
and the farrago of substances supposed to be proper or useful in 
the sick room. The injudicious use of mercurial, drastic, or saline 
purgatives at the outset of the disease, leads in the first instance 
to hypercatharsis ; and though this may be checked by astringents, 
we still have to apprehend an atonic state of the muscular coat 
of the intestines, aud its results as above described. The exces- 
sive use, or rather abuse, of drinks and fruits, and the slops sup- 
posed to be necessary to the fever patient, conduce to a like 
effect. 

The state of meteorism or tympanitis is always to be regarded 
as a formidable complication in fever; and when developed to an 
extreme degree and persistent for two or three days, resisting 
treatment, it is a symptom of all but fatal import. In the chapter 
on the treatment of fever, rules will be found laid down as to the 
management of the patient's diet and medicines ; and it will be 
found that moderation in medicines and aliments from the outset 
of the disease affords the best chance of obviating the occurrence 
of this as well as many others of the incidental lesions of typhus. 
When present the affection is best treated by turpentine stupes, 
carminative draughts, and suitable enemata ; while at the same 
time the system generally is well supported by stimulants and ju- 
dicious nourishment. Do what we will, however, many of these 
cases seem utterly intractable, when once tympanitis is established 
to any considerable degree ; the case is all the worse if the sto- 
mach is intolerant of food or medicine, while diarrhoea is present. 
When at the same time loud gurgling sounds give evidence of 
the presence of large quantities of air and fluid in the intestinal 
canal, the case is still more unfavorable. 
10 



146 TYPHUS. 

Hemorrhage from the mucous surface must be regarded as' 
an occasional though rare attendant upon typhus. Its true 
pathology seems to be, that it is a symptom related rather to the 
condition of purpura hgemorrhagica, so often found in connection 
with typhus epidemics in this country (Ireland), than with the 
typhous state itself. 

Astringents, such as tannic or gallic acid, acetate of lead, alum, 
perchloride of iron, or chromic acid, may be administered by the 
mouth, while the ice-filled plug may be applied to the anus. 

Hemorrhage from the stomach is an event of unusual occur- 
rence in typhus; it is to be treated on the ordinary principles, by 
the employment of any of the above astringents, iced drinks, &e. 

Diseases of the other viscera of the abdomen are of comparative 
rarity in typhus. Affections of the liver, spleen, and kidneys are 
very uncommon, if we except congestion of these viscera, which 
occurs to a variable extent in some cases. This state is seldom 
recognizable during life, and is only discovered in post-mortem 
examinations. Deposits in the mesenteric glands are likewise of 
extreme rarity in pure typhus. In this respect, typhus contrasts 
remarkably with typhoid, in which secondary processes of dis- 
ease, with deposits of ill-organized exudative matter, are so com- 
mon in the mesenteric glands and spleen, and occasionally in 
other parts. The practitioner must be on his guard not to mis- 
take for evidences of renal disease, the symptoms we have already 
noticed in connection with the urine. This secretion, we have 
already seen, may be scanty, high colored, and surcharged with 
lithates at an early period of the disease ; chemical examination 
shows us that the urea and other constituents are increased, all 
of which phenomena are to be interpreted as the result of in- 
creased metamorphosis of the tissues, showing itself in increased 
elimination of effete products by such emunctory organs as the 
kidneys. The kidneys, like other organs, partake occasionally of 
the tendency to congestion, and we sometimes find slight traces 
of albumen, and even of the red particles of the blood in the urine 
as the result of the renal substance being surcharged with blood. 
Albumen in the urine seems to have no other significance what- 
ever in fever than this, that it is the result of mechanical pressure 
of blood on the urinary tubules. At a later stage of the fever, 
we sometimes find the urine becoming ammoniacal, and contain- 



URINARY EXCRETION IN TYPHUS. 147 

ing phosphates in excess ; this usually happens when the case is 
excessively low and prostrate, and it is amongst other things an 
indication for high stimulation. In the latter periods of a case 
of typhus, we not unfrequently find that there is loss of voluntary 
control over the sphincters of the anus and urethra. Involuntary 
passage of the urine and feces is a grave and troublesome symp- 
tom in many cases of fever, but is not always a fatal one. In 
many cases the urine constantly dribbles away in small quanti- 
ties, the bladder is kept perpetually drained, and no mischief 
accrues to the patient beyond the soakage of the bedclothes, and 
the irritation of parts wetted by the urine. In other cases per- 
petual dribbling of urine goes on, and this is supposed to indi- 
cate that the bladder is empty; but on careful examination by 
palpation and percussion in the hypogastric region, the bladder 
is found of large dimensions, reaching high above the pubes, and 
containing several quarts of urine, which, on being drawn off by 
the catheter, is found to be turbid, and to have a highly ammo- 
niacal fetor. This state of the bladder seems analogous to that 
which we have before described as occurring in the intestines, in 
which there is a paralytic state of the muscular fibres, and a 
passive distension of these viscera from their accumulating con- 
tents. In the case of the intestinal paralysis, with meteorism, as 
before explained, we have a constant diarrhoea, but it drains 
away only a small amount of the liquids accumulated in the 
small and large intestines. In the case of the bladder, urine 
accumulates, paralysis of the muscular walls of this viscus ensues, 
a small portion of fluid dribbles away, and it is supposed that the 
organ is daily emptied, while in fact fetid urine is being accumu- 
lated in large quantities. Where this condition exists to an ex- 
treme degree, we find when the patient dies the bladder converted 
into an enormous passive sack, containing two or three quarts, 
sometimes more, of fluid, with a highly ammoniacal odor; the 
ureters are sometimes distended in such cases. It will be seen 
at once how necessary it is that we shall not take the report of 
friends, nurses, or other attendants, as to the state of the urinary 
secretion in typhus cases. We ought, indeed, to satisfy ourselves, 
by ocular proof, that urine is regularly voided every day ; the 
vesical region must be carefully palpated and percussed, and if 
there be a doubt on our minds, the catheter must be introduced, 
to test the actual condition of the bladder. 



148 TYPHUS. 

Suppression of urine. — This, always a formidable and constantly 
a fatal symptom, is not by any means common in typhus. It 
seems to be a more usual attendant on the remittent class of 
fevers than on those of continued type. It certainly is not so 
often met with in the fevers of these countries as in those of 
warmer latitudes. Suppression of urine, when it does occur, is 
always a symptom for most serious alarm. Sometimes it will be 
observed that there is a gradual diminution of the urinary secre- 
tion; occasionally it occurs in quite a sudden manner, and the 
catheter is introduced under the impression that there is retention 
of urine, but not a drop is brought away. The symptoms which 
arise in this condition are variable, and indeed of an entirely 
opposite kind in different cases. Thus we sometimes have symp- 
toms of narcotic poisoning ending in coma, while in other cases 
the patient remains in possession of his faculties almost to the 
last. Active measures must be at once employed in cases of this 
kind, including cupping and counter-irritation over the loins, with 
such medicines as the acetate and nitrate of potash internally. 
The infusion, tincture, and oil of juniper may likewise be used in 
suitable proportions; the oil of juniper may be used as an embro- 
cation dissolved in any convenient menstruum, in the proportion 
of two drachms of the oil to four or six ounces of the vehicleo 
It is to be said, however, that few cases of fever admit of success- 
ful treatment in which total suppression of urine has been present 
for a period of twenty -four hours. 

SECONDARY LESIONS OF THE CUTANEOUS SYSTEM. 

Under this head we have to consider a class of affections often 
of a formidable character. In the course of typhus fever, erythe- 
matous patches will be found to present themselves occasionally 
on various parts of the surface. They may be observed upon the 
anterior portion of the body as well as upon the posterior, but- 
most commonly upon the latter. In many instances these spots 
seem little more than the ordinary erythema fugax; they remain 
out for a day or two, and then disappear completely. The ap- 
pearance of such spots, however, should always put the physician 
on his guard, as they are often the precursors of sudden and 
violent, but low inflammation, leading in a short time to the 
complete destruction and death of the tissues engaged. In epi- 



BED -SOKES IN TYPHUS. 149 

demies in which the fever is of very low type, this kind of spha- 
celus must be expected, and if possible anticipated, in the parts 
subjected to pressure. Slight erythema is often the only symp- 
tom present in the first instance, and this is constantly overlooked, 
as in the prostrate state of the patient there is often no pain or 
uneasiness complained of. In many of such cases the patient has 
been lying on his back for days together, and it is only when he 
accidentally changes his position that the real state of things is 
discovered. In such cases it will happen that before the least 
suspicion is aroused, sphacelated patches, commonly known as 
bed-sores, have been formed upon the occiput or the ears; over 
the last cervical and first dorsal vertebras; over the inferior 
angles of the scapulae, the sacrum, or the nates, the backs of the 
thighs, calves of the legs, or heels. Other parts, as the elbows, 
will be also found affected in certain cases. Though parts sub- 
jected to pressure are those most usually affected, it is not to be 
supposed that pressure or position are the sole causes of this 
destructive form of inflammation. We know that in states of 
low innervation, as in hemiplegia or paraplegia, and various other 
forms of nervous lesions, low and rapidly destructive processes 
of inflammation take place, which often lead to sphacelus of the 
parts implicated. While, then, pressure or position may be the 
immediate cause of bed-sores on the occiput, sacrum, nates, or 
heels, we must look to the low state of the system as the predis- 
posing cause. 

It is worth while to trace the process by which an extensive 
bed-sore is established through its several stages. We find in 
the first instance an erythematous patch; this is observed in a 
day or two, sometimes in a few hours, to present a central part, 
a quarter to half an inch, two inches, or upwards in diameter, 
which is dense, and seems to have a deeply -seated base. Soon 
after a ring-like line of separation, with dark gray discoloration, 
may be observed to divide the dark central portion from the 
redder erythematous parts which surround it. As the affection 
progresses the separation of the central sphacelated portion be- 
comes more distinct, until it finally drops out, when the destruc- 
tive process will be found to have extended to the areolar tissue 
beneath the skin. Foul, deep, irregular cavities are thus suddenly 
excavated ; many of them extend by a burrowing process to a 
considerable distance. I have known instances in which these 



150 TYPHUS. 

sores, seated over the sacrum, were found to burrow to the dis- 
tance of three or four inches into the areolar tissue of the lumbar 
region. Bed sores are formidable from their immediate effects 
upon the system in the low state in which the patient is ; they 
are likewise to be dreaded in consequence of the long processes 
of suppuration, constituting an additional drain upon the patient's 
system for weeks and sometimes months, after he has got through 
the primary fever. Bed-sores most commonly occur at the end 
of the second or at the beginning of the third week of typhus ; 
this being the period at which the vital powers are at the lowest 
ebb, it is not surprising that many patients sink under the addi- 
tional shock of an extensive bed-sore. 

The first appearance of erythematous patches on the posterior 
portions of the body, or other parts subjected to pressure, calls 
for immediate treatment, with a view to check the process at the 
outset. As a general indication, any tendency to bed-sores is an 
additional reason for general stimulation, and for redoubling our 
efforts to support the patient's system by food, wine, brandy, and 
medicinal stimulants. Every effort must be made to save the 
affected parts from pressure, as by turning the patient on his side 
if the sacrum or nates be threatened. The ring-shaped elastic 
cushion is also an excellent expedient, and in extreme cases the 
water-bed or the strap bed (known as Corrigan's bed) will be 
found useful. Local stimulation is an excellent means, when 
used sufficiently early. With this view, erythematous patches 
occurring in suspicious situations may be washed with a strong 
solution of nitrate of silver (half a drachm or a drachm to the 
ounce), or pencilled over with the solid caustic. Camphorated 
lotions or turpentine may be used with a like view, mainly to 
stimulate and support the local vessels, and thus maintain the 
life of the part. When sphacelus has taken place, and the slough 
of dead skin and areolar tissue has fallen out, the cavity may be 
washed with tepid water, and stimulating dressings applied. In 
those cases in which fistulae present themselves, it will be neces- 
sary to syringe them out with tepid water, once a day at least; 
they may be then injected with a twenty or thirty-grain solution 
of caustic, and afterwards stuffed with lint or charpie, saturated 
with some stimulant dressing. Eesinous, spirituous, and vinous 
dressings, as well as those made with tincture of bark, were for- 
merly much in vogue ; but I know of no application so suitable 



GANGRENE IN TYPHUS. 151 

or effectual as that made by mixing equal parts of the balsam of 
copaiba and common castor oil. In the chronic stages of bed- 
sores I have known this remedy to be used with the greatest 
effect. 

In epidemics of the worst forms of typhus, more extensive gan- 
grenous destruction of the surface, and occasionally mortification 
of the extremities, have been met with. It will be very necessary 
to be our guard, in order that those extensive discolorations of 
the surface, which result from the association of purpura hemor- 
rhagica with the fever, shall not be mistaken for the appearances 
of gangrene, a thing not improbable from the deep, livid, purplish 
tint which those parts assume in typhus which are the seat of 
extensive patches of purpura. There can be no doubt, however, 
of the occurrence of extensive mortification of superficial parts, 
as well as of the extremities, in the famine fever of Ireland. I 
have myself witnessed the following striking instance of death in 
life ; it exemplifies some of the singular conditions occasionally 
to be met with in the typhus gravior. The patient, in the last 
stage of chronic starvation, and with the typhus crasis character- 
istically developed upon him, was yet able to walk some distance 
to seek admission into the workhouse hospital of his district. On 
baring his chest to examine him, we were shocked to perceive the 
whole of the superior anterior part of the right side of the chest 
converted into a dark olive-green, jelly-like, and tremulous mass. 
The condition of sphacelus in this case was the most complete 
and extensive I have ever seen; and, as well as could be judged, 
it appeared to implicate the texture of the great pectoral muscle, 
as well as the integument over it. There could be only one end 
to such a case. 

Mortification affecting part of the foot or the leg may also be met 
with in low typhous epidemics. In these cases, there has usually 
been a defective condition of nutrition for some considerable 
period before the fever set in ; and since the patient was attacked, 
exposure to cold in a damp unwholesome atmosphere, and upon 
a bed of foul and rotten straw or upon the hard floor, without 
covering of any kind. Most of these cases prove fatal; but if 
the process of mortification engages only a limited surface, the 
patient must not be abandoned as altogether beyond hope. 
Stimulants are called for in the most liberal doses, and the part 
or limb must be wrapped in cotton, and appropriate means used 



152 TYPHUS. 

to keep up the circulation in the remaining portion of the ex- 
tremity. 

G-landular swellings occasionally present themselves in various 
parts of the body during the course of typhus, and in some in- 
stances to such an extent as to give quite a marked and special 
character to the case. In a minor degree we find such swellings 
now and then to occur in the axillae and the groins, but as they 
subside after a time, and demand no medical interference, they 
are passed over. Some few instances are, however, on record, in 
which the bubonic affections assumed very formidable characters. 
One of the most remarkable cases of this kiud I am acquainted 
with is that of the man Horncastle, described in Dr. Stokes' Lec- 
tures on Fever. Large and foul buboes formed in various parts, 
and suppurated ; there was extraordinary prostration, and the 
amount of stimulants required to bring the patient through was 
enormous. The bubonic affection has likewise been noticed in 
the London Fever Hospital, and to so marked a degree, that a 
celebrated Egyptian physician, on seeing some of these cases, is 
stated to have declared that in Egypt they would be set down as 
examples of the plague. 

The treatment consists in careful poulticing, opening the buboes 
if necessary when mature, and free general stimulation with wine, 
brandy, ammonia, bark, &c. Having considered, seriatim, the 
secondary lesions which affect the various organs in typhus, we 
may sum up, under the head of "bad signs," a variety of symp- 
toms, which will be of use to the junior physician, in directing 
his prognosis in many cases of fever. 



BAD SIGNS IN TYPHUS. 

1. It is a bad sign if the typhus prostration is early developed 
and profound, and if the skin be dark-colored and the extremi- 
ties cold. 

2. It is a bad sign if the patient cannot sleep at any period 
after the seventh day. 

3. It is a bad sign if the patient is wakeful, delirious, and un- 
manageable; and the case is all but hopeless when the tartar 
emetic and opium plan fails to give relief in this class of affec- 
tions. 

4. Continuous sweats occurring between the seventh and twelfth 



BAD SIGNS IN TYPHUS. 153 

day, and unattended with relief to the pyrexial state, are of un- 
favorable omen. 

5. "When there is tendency to coldness of the breath with 
u sunken" face and coldness of the extremities, the case must be 
looked upon as of very low type, and there is reason to appre- 
hend death by asthenia. 

6. When the pulse rises above 120, becoming at the same time 
small and thready, the state of the patient is formidable, unless 
stimulants are found to lower the rate and expand the volume of 
the pulse. 

7. If there be thumping action of the heart, and feeble pulse 
at 130 or 140, the case is a hopeless one, unless the circulation 
can be controlled and strengthened by stimulants within twenty- 
four hours. 

8. When to the last-named condition is added coldness of the 
breath and tongue, with cold sweat upon the surface, the patient 
may be considered in the majority of cases as past all hope. 

9. A tendency to sighing presents itself in many patients for 
several days together ; the patient may have no formidable se- 
condary lesion of any kind 5 but is yet nervous and apprehensive 
about himself from the beginning; such cases not unfrequently 
occur in persons of the better classes, including clergymen, law- 
yers, and physicians. A presentiment of death often haunts 
individuals at other times remarkable for strength of mind ; this 
presentiment often becomes a realized fact, by the death of the 
patient at an early period, and in an unexpected manner. While 
we take care not to betray our own suspicions, we must give the 
utmost attention to this class of cases, with a view to anticipate 
sinking by liberal stimulation and other appropriate means of 
treatment. 1 

10. If wine disagrees with the patient, that is to say, if it excites 

1 No class of cases affects the medical practitioner in Ireland more than those 
occurring in the persons of his own brethren in the profession, and the Catholic 
clergy, as well as those of other denominations, who, next to the physician, share 
most of the perils of an epidemic of typhus. When struck down by the fever 
themselves, they have vividly in mind the leading symptoms of the last fatal 
case which they have witnessed amongst their nearest and dearest friends, or 
amongst their parishioners or patients. Such impressions have the worst pos- 
sible influence, and depress the patient beyond measure. Some of the worst 
battles which the physician will have to contest- with disease, are to be encoun- 
tered whilst dealing with such cases. 



154 TYPHUS. 

the heart and brain instead of tranquillizing them, extreme danger 
must be apprehended. 

11. When hiccough is present for more than twenty -four hours 
and becomes uncontrollable, there is little chance of saving the 
patient. 

12. If unmanageable tympanitis exist, with or without diar- 
rhoea, no effort will save the patient, in the majority of instances. 

13. Eloccitatio, or picking of the bedclothes, is a symptom of 
serious import; the same is to be said of subsultus tendinum ; 
but neither of them is a necessarily fatal sign, though often con- 
sidered so. 

14. If passive bronchial effusion take place, and if stimulants 
and expectorants, including turpentine, fail to produce evacuation 
of the bronchi within a limited time, the patient must be consi- 
dered in extremis. Extensive typhoid pneumonia gives the same 
indications. 

15. Involuntary discharges of the urine and feces, especially 
when they occur at an early period of the case, are very unfavor- 
able, but by no means necessarily fatal symptoms. 

16. Erysipelas, gangrene, and sloughs, especially if occurring 
on the back, and if of a great extent, are often fatal. 

There are a few incidental lesions occurring in typhus, which 
do not readily find a place amongst the ordinary secondary lesions. 
Deafness is sometimes observed in one or both ears about the 
middle periods of typhus. It is hard to say upon what ana- 
tomical condition it depends. It may be explained in some cases 
by the general thickening and turgescence of the fauces, leading 
to partial or complete occlusion of the Eustachian tube. In other 
instances it seems to be due to the swelling of the parts in the 
parotidsean region. Deafness is regarded by some practitioners 
as a favorable sign ; I cannot conceive why, and I believe it to 
be a condition which has usually no connection whatever with 
the result of the case. 

Parotitis. — Inflammation of the parts in the parotidsean region 
occurs at the close of some cases of typhus ; there is reason to 
think that it is not the parotid gland itself which is implicated, 
but one or more of the lymphatic glands imbedded in its surface. 
The swelling sometimes reaches to a considerable extent, and by 
pressing upon the external meatus of the ear becomes one cause 



TEEATMENT OF TYPHUS. 155 

of deafness. Abscesses are occasionally formed, and become 
troublesome, though otherwise insignificant sequelas of the fever. 

Symptoms of nervous irritation are occasionally presented in 
different parts in typhus, and give rise to nervous twitchings 
during the course of the fever, and after its cessation to slight 
semi-paralytic states in various parts of the body, which last 
sometimes for two or three years subsequently. This condition 
is sometimes found to affect the sciatic nerve of one extremity. 
We have known a case in which the ulnar nerve of one side was 
affected, both sides of the little finger and the ulnar half of the 
ring-finger being anaesthetic for about five years after the patient 
recovered from the fever. 

Subsultus tendinum, or spasmodic twitchings of the muscles or 
tendons in the legs and arms, is a symptom always of grave, often 
of fatal, import ; it is often most distressing, and an attendant is 
required to press his hands on the legs of the patient to retain 
them in a state of temporary tranquillity. Musk, camphor, strong 
broths, and free stimulation are imperatively called for in this 
class of case. 



TEEATMENT OF TYPHUS. 

In undertaking the management of a case of typhus, the first 
and most important rule is to secure complete and absolute con- 
trol over the case, and, what is perhaps of more consequence, 
over every one, whether relative or domestic, in attendance upon 
the patient. The consulting physician, when called to the sick- 
room of a person in typhus, often finds things in a state of utter 
confusion ; and what between officiousness and over-anxiety to be 
of use, on the one hand, and insane alarm on the other, finds it 
difficult, if not impossible, to get a good insight into the history 
of the case, and its progress up to the time he first sees it. 
Nothing is more requisite than to establish order and regularity 
around the bedside of a patient in typhus, and to substitute suc- 
cessive watches and relays of fresh and active attendants for the 
wearying, exciting, and protracted night and day watchings of 
the over-anxious mother, wife, or sister. No doubt heroic in- 
stances will be met with from time to time of individuals com- 
bining devotion and courage with every requisite of judgment 
and control over their own feelings, and so insensible to the 



156 TYPHUS. 

fatigues of night watching, that they will be enabled to nurse a 
patient successfully through a three weeks' typhus. Such in- 
stances are, however, rare, and under ordinary circumstances it is 
far better to have a regular alternation of night and day attend- 
ants. 

Free ventilation, without draughts, must be secured in the 
sick-room of a typhus patient, and is a condition of great im- 
portance. It is desirable that the temperature should not pass 
beyond 60° at any time; and of the two, I believe excessive cold 
is less injurious than excessive heat in typhus. A fire need not 
be interdicted in winter, but the above condition — viz. an average 
temperature of 60° Fahr. — must be strictly attended to when 
practicable. The patient's bedclothes must be sufficient and 
comfortable, without being too thick or heavy. It will be a good 
plan to do away with curtains of all kinds; and on the whole, a 
well-made hair-mattress, upon an iron bedstead, is far preferable 
to a feather-bed; it admits of the patient's linen being more 
easily changed, and the posterior surface of the body can be more 
readily examined from time to time, and attended to, if there 
seems any disposition to the formation of bed-sores. 

Food and Drink. — It is often thought that the food and drink 
of the patient in typhus are subjects in which the physician has 
no right to meddle; and yet it is incalculable how much mischief 
is done in fever cases by injudicious management of the patient 
with respect to his ordinary food and drink. Ill effects occur in 
two ways: either the patient is pressed with various articles of 
food and drink until his stomach is surfeited; or, on the other 
hand, the patient is literally starved, under the impression that 
food will add to the inflammatory excitement which is supposed 
to be present. The starvation plan of treatment, based on a 
phlogistic pathology, has, when combined with depletion, con- 
signed numbers to the grave. Impressed with the force of this 
truth, the late Dr. Graves was in the habit of saying that he 
wished it to be inscribed on his tomb, as his most honorable 
memorial, that he had fed fevers. In this is recognized a great 
practical truth: the maintenance of life supposes metamorphosis 
of the tissues, and metamorphosis of the tissues supposes nutri- 
tion, which in its turn requires a regular supply of aliment to the 
stomach. It must not be forgotten, however, that the fever 
patient is not in a condition to assimilate nutritious materials to 



FOOD AND DKINK IN TYPHUS. 157 

the same extent as if he were in the state of health. The supply 
of food must therefore be of the mildest and blandest kind, while 
it is moderate in quantity. Broths, soups, nutritious jellies, and 
such like liquid aliments are useful ; but I see no objection to the 
patient getting in moderate quantities any ordinary kind of light 
solid food, roast or boiled, if he chooses to ask for it; and this I 
have known patients occasionally to do. Indeed Stokes relates a 
case, at once singular and instructive, in which a delicate patient, 
supposed to be moribund in fever, was provoked by the savory 
odor of corned beef and cabbage, which were being dressed in the 
kitchen, and insisted on a substantial plate or dishful being 
brought to her bedside. It was thought of little consequence to 
indulge the freak of a dying person; but, strange to say, the 
patient recovered straightway, despite this outrageous contempt 
for the rules of scholastic therapeutics. The rational conclusion 
from this and many similar cases is obviously that a regular 
supply of nutrient materials is indispensable to the maintenance 
of life in typhus as well as in health. We must avoid excess and 
repletion, on the one hand, and weakening the already low system 
of the patient by starvation, on the other; it is a good common- 
sense plan to allow the patient at the usual meal times a reason- 
able amount of light nutritious food. Thus, between nine and 
ten o'clock in the morning, let him have a cup of tea or coffee 
well diluted with milk, with toast ; one o'clock, as the usual hour 
of lunch, will be a good time for giving a couple of glasses of 
sound wine, with a biscuit or something equally light; between 
three and four o'clock the patient may have something in the 
shape of dinner, and this may be either good strong beef-tea with 
toast, or occasionally a little light animal food, if the patient de- 
sires it, and is in a condition to bear it; at, or about, eight P.M. 
the patient may have some very light and unexciting supper, as 
arrowroot, and this is another excellent time for administering a 
couple of glasses of some cordial and sustaining wine. Now let 
there be no mistake as to the indications here detailed; the object 
is to support the system by a moderate and judicious supply of 
nourishment at seasonable intervals, but to avoid repletion of the 
stomach, on the one hand, by the slops and endless farrago of the 
sick-room, just as much as starvation on the other. It will be 
found that by thus regulating the diet of the patient, we shall 
most readily save him from the teasing and over-anxious solicita- 



158 TYPHUS. 

tions of friends, who are perpetually, through mistaken kindness, 
urging upon him food and drinks in every conceivable shape, 
besides fruits and condiments of various kinds, which with his 
medicines do not leave his stomach one unoccupied half hour in 
the day. The state of perpetual drench in which the stomach is 
thus often maintained between physic and slops has the most 
injurious effect in many cases. While the patient can digest and 
assimilate a certain moderate amount of nutriment in typhus, the 
stomach and intestines are wholly incapable of mastering the 
heterogeneous ingesta thrown into them in many instances. Irri- 
tation of the gastric membrane, with gaseous distension and 
nausea, vomiting, and sometimes incontrollable hiccough, are but 
too often the consequence. In other instances tympanitis becomes 
the most prominent feature, and then, as already explained, we 
have a paralytic state of the intestines to deal with, in which 
there may or may not be nausea and vomiting, with ineffective 
irritable diarrhoea, and at the same time a passive accumulation 
of gases and liquids in the cavity of the abdomen. 

When the patient is convalescing, the utmost care must be 
exercised in the choice of food, and the more solid meats, as beef 
and mutton, must be withheld for at least a week or ten days after 
convalescence has well begun. I have known the incautious use 
of mutton chop, which is often craved for by the patient, to pro- 
duce diarrhoea, and occasionally a dysenteric attack, lasting for 
some weeks ; this weakens the patient very much, throws him 
back, as the saying is, and more rarely sets up an irritative 
secondary fever; in exceptional cases death has ensued, with too 
much reason to trace the commencement of the fatal symptoms 
to the incautious use of solid animal diet. 

Thirst. — This is often a symptom of an urgent character, and 
there are few cases of fever in which thirst is not a trouble to the 
patient, and a difficulty to the physician. It is no doubt right 
that a natural desire should be gratified, and nothing is more 
imperative and uncontrollable than the perpetual craving for 
drink in many cases of typhus. There is no harm in allowing 
the patient a moderate amount of cooling drink of almost any 
kind from the outset; but we must resolutely set our faces 
against drenching the patient with slops of every conceivable 
nature, and in unlimited quantity, at every moment that he calls 
for drink. Cold water in mouthfuls, very slowly swallowed, often 



BETENTION OF UKINE IN TYPHUS. 159 

allays the inordinate thirst more than deep draughts rapidly and 
greedily swallowed ; small lumps of ice placed on the tongue, and 
allowed to dissolve slowly, likewise assuage thirst ; subacid but 
well-ripened fruits, as oranges and grapes, are likewise occasion- 
ally useful; good French wines, as Claret and Burgundy, mixed 
or not with water, as the case may otherwise demand, are also 
efficacious ; effervescent draughts, as soda and seltzer waters, are 
often grateful, and, where circumstances admit of it, French or 
Khenish effervescing wines are particularly pleasing to many 
patients. Amongst specifics against thirst, the preparations of 
camphor are those most often useful; the ordinary Mistura cam- 
phors, in half ounce or ounce doses, may be exhibited, and often 
with excellent effects.. Murray's fluid camphor is also of much 
use. 

Heat of skin is occasionally one of the most intolerable symp- 
toms in typhus. The cutaneous surface may be much relieved 
by careful rubbing with soft dry Turkish towels once or twice in 
the day ; sponging the body and limbs with warm vinegar and 
water, if done so as to avoid the risk of chilling the patient, will 
be found most grateful and refreshing. The effect of this is ex- 
cellent ; it thoroughly cleanses the skin, and for a dry hot surface, 
with intense calor mordax, substitutes a softened state of the in- 
tegument, with but a very moderate and quite tolerable heat for 
some hours subsequently. 

Attention to the state of the primse vise is of the utmost con- 
sequence in the management of fever cases. An occasional enema 
of soap and water, when the action of the intestines is sluggish, 
will promote sleep and the general tranquillity of the patient, 
relieving heat of head, and even delirium and restlessness. Ke- 
tention of urine, though not a very common occurrence, is one 
which, when neglected, may give rise to symptoms of the most 
alarming kind, and, if allowed to continue unrelieved till too late, 
may be the direct and sole cause of a fatal issue in a case which 
otherwise would in all probability end favorably. Thus I have 
known of an instance in which a patient, a female, on the seven- 
teenth or eighteenth day of fever, was in a moribund condition 
after protracted convulsions verging into coma from the ignorance 
or neglect of her attendant (a homoeopathic practitioner). An- 
other opinion (that of Dr. Corrigan) was sought when the case 
was in extremis, and then only was it ascertained that the bladder 



160 TYPHUS. 

was distended to above the umbilicus; the catheter drew off a 
bucketful of most foul and putrid urine, and the patient recovered 
with the sequel of a chronic cystitis, which lasted some three or 
four months. 

Both in private practice, and in patients presenting themselves 
in hospital, cases are often met with, which, so to speak, have 
been "spoiled" from the outset. Under the mistaken impression 
that an abortive action may be induced in the fever, various spe- 
cific plans of treatment are still in vogue. Thus, one practitioner 
supposes that he can prevent his cases running on into regular 
typhus by vomiting them, another by purging them, or depleting 
them from the outset. Any of these processes may have a most 
decided and unfavorable influence over the patient's chances of 
recovery. This is especially true of the plan of treatment by 
emetics and purgatives. 

Physic. — As a general rule, it may be said that physic is to be 
avoided in typhus, unless and until it is clearly required, and 
then it should be administered with well-defined purpose. Com- 
mon sense seems the best guide in these cases ; and yet there is 
often great difficulty in satisfying the expectations and require- 
ments of friends, unless the physician seems to be actively phy- 
sicking his patient from the beginning to the end of the case. A 
little moral courage and firmness, if based on real pathological 
knowledge, will, however, usually overcome difficulties of this 
kind. 

From the views that we have inculcated throughout of the 
pathology of fever, it is hardly necessary to say that no specific 
plan of treatment in typhus will be here recommended. We have 
no faith in efforts to cut short the fever ; we cannot advise emetics 
for the purpose of causing the fever to abort ; we cannot propose 
to ourselves to sweat the patient out of his fever ; nor can we hope 
to effect the same object by purgatives or diuretics. What then, it 
may be asked, is the duty of the physician at the bedside of a patient 
in typhus ? Is he to stand idle, and wait till this or that striking 
symptom calls for his interference ? Certainly not ; he knows 
from experience that the tendency of the disease is for the patient 
to sink, and, as it were, for life to go out by a gradual process of 
extinction of the vital powers. He is then to anticipate by every 
means within his power this tendency to sink. He must in fact 
feed, support, stimulate, and so far, as well as in other ways more 



GENEKAL STIMULATION AND LOCAL DEPLETION. 161 

distinctly medical, treat the case while it is under the influence of 
the disease, as to make it live through the period of the fever if 
possible. He is in the position of the captain of a ship, who skil- 
fully makes his vessel ride out the storm, not by any one specific 
mode of action, but by a combination of skill, intrepidity, and 
readiness, which enables him to see at once every possible source 
of danger, and use every means at his command to obviate it. 
This may be looked upon as the first great cardinal rule in the 
management of fever. 

While feeding, supporting, and stimulating his patient, the 
physician must be forever on the watch for the several local 
complications which so often, as we have seen, present themselves 
incidentally in the course of typhus, invading now this organ, 
now that. He must be prepared to anticipate these affections, 
and must make it a part of his daily duty to examine with care 
the various important organs, as those of the head, chest, and 
abdomen, And while he carries out the all-important indications 
already given as to feeding, supporting, and stimulating the 
patient, he must be prepared to act boldly, as experience dictates 
to be best and safest, with regard to the local secondary affections 
before enumerated. Thus it may happen that while he is obliged, 
by the presence of a typhoid pneumonia, to abstract some ounces 
of blood by cupping from the chest, he is at the same time called 
upon to stimulate his patient's system by an unlimited supply of 
wine, or it may be stronger stimulants, which may afford the only 
possible chance of saving life. 

At the outset of typhus there is, in some cases, such an amount 
of pyrexial reaction, as to indicate the employment of the ordi- 
nary febrifuge remedies. Indeed, if given with caution, diapho- 
retics are useful in a good many cases during the first week; they 
must not, however, be pushed to the extent of producing exces- 
sive sweat, or iu any way weakening or lowering the system. 
The acetate of ammonia or the citrate of ammonia given in 
effervescence will be often found grateful. The Pulvis Jacob i 
veri and the ordinary Pulvis antimonialis are also safe if given in 
moderate doses. Tartar emetic is not, in my opinion, either a 
safe or advisable remedy in typhus. We must bear in mind that 
we have to deal with an extremely prostrate state of the circula- 
tion, over which we know antimony to have much depressing 
11 



162 TYPHUS. 

power. All medicines of the diaphoretic class must be used with 
the greatest possible caution in typhus. 

We have so constantly alluded to the question of venesection 
in typhus, that it is only necessary to enter our protest against 
it here formally once more. In saying this, I am perfectly well 
aware that some few physicians still pursue the practice of bleed- 
ing in typhus ; but as once forcibly remarked to me by Stokes ; it 
only proves how hard it is to kill some people. 

Under the head of periodics, preparations of bark have been 
used in typhus, but the indications are neither so clear nor so 
successful for the use of these drugs in typhus as in other types 
of fever. While then we cannot say that the decoction or tinc- 
ture of bark, or the sulphate of quinine, is very clearly indicated 
for the treatment of the typhous group of fevers, there are many 
cases undoubtedly in which cinchona or quina will be found of 
use. In general it may be said that bark, in any form, constitutes 
the best and simplest medicament which can be employed in those 
cases in which there is no secondary complication, and when no 
positive indication for specific treatment exists. Now in many 
of such cases, with a view to the moral effect upon the patient 
himself, as well as for the satisfaction of friends, it is desirable 
that some medicine should be administered at stated intervals. 
This expedient is not only a justifiable but a necessary one: it 
establishes order, maintains confidence, and, where such a medi- 
cine as quinine is used, is of positive service to the patient. 

We will now suppose a case of fever, under judicious manage- 
ment, progressing to the seventh or eighth day : bland nutritious 
food has been supplied at regular periods ; every attention has 
been paid to the state of the primse vise ; the pulse, the tongue, 
and the skin have been carefully watched ; and there is as yet 
nothing about the case to indicate positive danger, or to call for 
active interference on the part of the physician. In the hands 
of an experienced practitioner, a case such as we have just indi- 
cated will, in all probability, be brought to a favorable issue ; on 
the contrary, in the hands of a rash and inexperienced practi- 
tioner, the events of the next three days may bring the patient 
to death's door, and in many such instances, life is lost. The 
fundamental difference in the two cases will be found to be this: 
that in the former cases, the natural tendency to sinking and col- 
lapse which characterizes the fever has been anticipated ; in the 



USE OF CLAKET AND BURGUNDY IN TYPHUS. 163 

latter, no precautions have been taken against the tendency to 
sink at this period of the fever ; and it may be, and often is, the 
case, that the treatment pursued, whether by purgatives or diure- 
tics, or again by general depletion, has hurried on the fatal issue. 
It is precisely at this period, between the seventh and tenth day, 
when the symptoms present give an all but negative result, that 
the experience of the practical physician who has seen much of 
typhus is of such value to his patient. This is the period when 
a moderate amount of stimulation and moderate nutriment, ex- 
hibited by a bold but skilful hand, prevent the patient from pass- 
ing into the typhous collapse, so often fatal both in endemic and 
epidemic visitations. 

It is extremely difficult to lay down any definite rules of treat- 
ment for cases just at this period. In general, however, it may 
be said that it is both safe and judicious practice to exhibit wine 
(in small quantities at first) on the seventh or eighth day of the 
disease. It requires the nicest j udgment in these cases to determine 
how far we may go with stimulation. It is of less consequence 
to the patient, however, in most cases to err by giving wine too 
early or in excessive quantity than to defer it too long. It is 
the safer plan, therefore, to administer a few ounces of wine, ex- 
perimentally as it were, during the first day. If no excitement 
of the pulse or heart be produced, the stimulant may be kept up, 
for we must bear in mind that prostration and sinking are the 
general characteristics of the disease. In some cases wine given 
even in small quantities excites the heart and pulse, and in such 
instances it is rarely beneficial. As we have before shown, if 
cerebral excitement and the dry baked condition of the tongue 
are produced by wine, it is worse than useless to continue its ex- 
hibition. The seventh day may be taken as that on which we 
may commence the stimulant plan of treatment, cautiously, as 
before remarked, and as it were experimentally ; but I believe it 
would be better to run the risk of stimulants disagreeing in a 
few cases, than in the majority to allow the prostrating efforts of 
the disease to steal a march upon us. 

It is impossible to state what quantity of wine will be required 
in different cases, but we may commence with from three to six 
ounces as a general rule. In private practice, and in families 
where we know the cost of wines is not a matter of consideration, 
the higher class of French wines may be used with great advan- 



161 TYPHUS. 

tage in the first and second weeks of typhus ; they produce an 
exhilarating effect without exciting the heart or brain. Lafitte 
and Chateau Margaux are excellent for this purpose ; Yolnay or 
Charabertin are suitable where a more considerable effect from 
wine is desirable, as these Burgundy wines have greater body 
and strength than those of the Claret vintages. Sherry and 
Madeira are useful, and must be employed where early sinking 
is imminent. Port answers the same purpose, but is heavier on 
the stomach. The effervescent wines, whether French or Rhenish, 
are very refreshing, and especially useful where thirst is much 
complained of. 

In hospital practice our means are of course much more limited, 
and we must be content with sherry or port; whiskey and water 
may often well supply the place of any wine, and when sinking 
seems imminent, hot whiskey or brandy punch forms one of the 
best and most effective stimulants. When the case is in extremis, 
the best wine is but a poor substitute for sound brandy or whiskey 
punch, which must be given ad libitum. But the great secret in 
reference to stimulants is, I believe, not so much to give them in 
large quantities when the patient is in extreme danger, as to 
anticipate sinking by the timely administration of wine or brandy. 
It is therefore a safe rule to commence the use of some stimulant 
on or about the seventh day, being guided by the nature of the 
case as to what class of stimulant we shall select. There are 
many memorable cases on record, which prove the extraordinary 
tolerance of stimulants in fever; the case of one patient, given by 
Stokes, cannot be easily paralleled. Within twenty-one days he 
consumed twenty-four bottles of wine, besides which he used six 
bottles of brandy, a quantity sufficient to keep another individual 
in a state of permanent intoxication, but which had only the effect 
in him of keeping the system up to par, without ever producing 
the slightest approach to intoxication. In the exhibition of wine, 
the state of the tongue, the pulse, and the heart, constitutes our 
chief guide as to whether the case is improving under its use, or 
the contrary. Thus if the tongue becomes moist, moderate in 
volume, and steady when protruded, without tremulousness, it is 
ail but certain the exhibition of wine is agreeing with the patient. 
If, on the other hand, the tongue becomes dry, crusted, and 
tremulous, the chances are that wine will not do in such a case. 



USE OF MUSK AND CAMPHOR IN TYPHUS. 165 

~We have already fully considered the indications furnished by 
the pulse and heart. 

Where wine fails; or shows a tendency to excite the brain and 
nerves, ethereal preparations will sometimes be borne with good 
effect. The nitric, sulphuric, or chloric ether may be exhibited 
in any simple vehicle, in doses of twenty to sixty drops. Carbo- 
nate of ammonia or the aromatic spirits of ammonia may be 
given for the same purpose. But as carbonate of ammonia has 
a purgative effect in some cases, its exhibition must be watched 
carefully. It is, as before stated, an excellent addition to the 
senega mixture, where no irritation of the bowels exists. 

Musk and camphor are remedies of some value where depres- 
sion with nervous excitement exists ; musk may be given in from 
two to ten grain doses, and is often highly efficacious. It is well 
suited for patients of high nervous temperament, and in the inci- 
pient periods of what we have called the delirium tremens of typhus. 
Its expense is the only objection to its use. The fluid camphor 
is also an excellent remedy, and it is often useful in cases of de- 
lirium such as we have described, as well as in others where 
nausea prevails to any extent. 

In a complicated case of typhus at an advanced stage, the junior 
physician is often at a loss to know whether stimulants are acting 
favorably, or the contrary, and whether their use should be per- 
severed in or not. The following rules, furnished by a physician 
of great practical experience, will be found reliable as guides in 
the administration of wines to a patient in t}^phus fever. 

1. If the tongue become more dry and baked, it generally does 
harm ; if it become moist, it generally does good. 

2. If the pulse become quicker, it does harm ; if it be rendered 
slower, it does good. 

3. If the skin become hot and parched, it does harm ; if it be- 
come more comfortably moist, it does good. 

4. If the breathing become more hurried, it does harm; if it 
become more deep and slow, it does good. 

5. If the patient become more and more restless, it does harm ; 
if he become more and more tranquil, it does good. 

In cases of low type and without complication, where we have 
a good and reliable private cellar to draw upon, the treatment 
may be often made to consist in great part of the liberal use of wine. 
If the patient has a choice it may be indulged, and to prevent his 



166 TYPHUS. 

tiring of the repetition of one kind of wine constantly, we may 
alternate between Clarets and Burgundies on the one hand, and 
the Spanish and Portuguese wines on the other. In a case 
recently treated by myself in conjunction with a very able and 
accomplished physician, in the south of Ireland, and in which we 
had likewise the assistance of another gentleman of considerable 
experience, the stimulation employed was almost entirely by 
wine. For days together the patient had three full glasses of 
best pale dry sherry, three of claret (Lafitte), and three of prime 
old port, with some three glasses of mulled port in addition. 
Wine was given by night as well as by day in this instance, less 
frequently of course in the latter period. This case recovered. 

GENERAL OBSERVATIONS. 

Typhus, though in some respects so formidable a disease, is in 
other aspects one satisfactory to the patient and to the practi- 
tioner. The progress and duration of typhus are well defined, 
and if the case be not fatal, the disease is rapidly and finally 
extinguished, and complete convalescence is speedily brought 
about in the majority of instances. A latent tuberculous ten- 
dency may, it is true, be called into play just when the fever is 
coming to a close, but this is certainly a rare and exceptional 
occurrence. Inflammations in the parotidaean regions occasion- 
ally leave troublesome swellings after the fever has subsided. 
In other instances, bed-sores may degenerate into chronic fistulas, 
which require attention for a couple of months, or even a more 
protracted period, subsequent to the attack of fever. 

With the exceptions just indicated, and making due allowance 
for its mortality, typhus fever is, perhaps, one of the safest dis- 
eases for the patient to have passed through. In common par- 
lance, "it leaves no sting behind it ;" while at the same time one 
attack of typhus confers a very great, though not an absolutely 
complete, immunity from a second attack of the disease. In- 
stances do occur, however, in which the same individual suffers 
from a second, or even a third attack of the disease, but they are 
of most extreme rarity. The constitution often seems to undergo 
a renovation ; when the patient has passed through typhus, he 
will be observed to become more robust, and this as well in the 
case of adults as in the young of both sexes. In some cases 



CONTAGION IN TYPHUS. 167 

there is a decided tendency to obesity after the fever, and in 
youths the process of growth is often accelerated. So far, then, 
from the system being impaired by an attack of typhus, I believe 
that the life of a patient who has passed through this disease in 
its pure form is of improved commercial value, and ought to be 
insured upon favorable terms. I know of but one unpleasant 
consequence resulting from typhus — I allude to the occasional 
falling off of the hair during and subsequent to convalescence. 
It grows well again in some cases, but most often it fails to be 
reproduced as abundantly as before. Having this result in view, 
I believe it would be better to shorten the hair by careful cutting, 
whether in males or females, at the commencement of the second 
week of the fever. If required by the state of the head or 
cerebral organs, the hair may be cut close or shaved without 
much scruple, knowing as we do that it will eventually fall out. 
We have no right, however, to make hasty and inconsiderate 
orders for the shaving of the head, till we are satisfied that it is 
a necessary step. We may here remark on the singular tendency 
to the development of lice, in extraordinary multitudes, on the 
hair of the head and other parts of the body in cases of typhus ; 
and this in individuals of the most scrupulously delicate and 
cleanly habits. The powdered Stavis agria is of use in destroy- 
ing these vermin ; it may be sprinkled through the hair pretty 
thickly for the purpose. Mercurial inunction is also fatal to 
them, but the head must be shaved in some cases before they can 
be entirely got rid of. Do what we will, however, their vitality 
cannot in some instances be destroyed while the fever lasts, but 
on its cessation they gradually disappear. 

With respect to the question of contagion in typhus, I have 
much difficulty in expressing myself. It would be idle to look 
to contagion for the origin and propagation of the wide-spread 
epidemics of typhus which have so largely decimated these 
countries. Whether personal contagion be possible in typhus 
under a system of perfect ventilation, I am not prepared to say. 
But I can have no manner of doubt that under existing condi- 
tions, as found in the sick-room in private, or in the wards of an 
hospital, the vitiated atmosphere which surrounds the typhus 
patient is capable of generating the same disease in those previ- 
ously in perfect health. 

The mortality in typhus is very formidable, being not loss 



168 TYPHUS. 

than one in three in most of the Irish epidemics, and sometimes 
higher. As a general rule, the mortality seems greater amongst 
intemperate persons than amongst those of well-regulated habits; 
it is also greater amongst the upper classes in proportion to the 
number of those attacked, and in males than in females. Age, 
however, seems to have an important influence in this last re- 
spect. In young persons of both sexes, under twenty years of 
age, the mortality in typhus seems the same in males as in 
females. • In persons above twenty years of age, nearly twice as 
many males die as females. 

Typhus has been from the earliest times a formidable disease 
in Ireland; and in the works of Eutty, Eogers, O'Connor, M'Bride 
and others, very excellent descriptions of typhus cases may be 
read, showing an extraordinary similarity to the cases we now 
daily meet with. 

Under the name of typhus syncopalis, or sinking typhus, a very 
fatal form of fever is indicated. Its chief characteristics are a 
tendency to rapidly fatal issue from syncope, with general failure 
of the powers of life. It does not seem to be positively deter- 
mined that the disease is strictly a form of typhus. Cases of this 
form of fever occurred during the celebrated siege of Saragossa 
in 1809, and elsewhere during Napoleon's campaigns ; somewhat 
similar cases are related by American authors. 

The "Febris bellica," which has at various times decimated 
Europe in periods subsequent to the great wars which agitated 
the continent, seems to have embraced various forms of Con- 
tinued fever, typhus amongst the rest. In the late Eussian war 
typhus prevailed amongst the Allied as well as the Eussian 
troops, but, as I have elsewhere shown, it was not the predomi- 
nant type of disease. 



TYPHOID FEVER. 169 



CHAPTER VII. 

TYPHOID FEYEK. 

Typhoid, or, as it is sometimes designated, Enteric fever, con- 
stitutes a variety of disease well distinguished from typhus in 
certain of its clinical features, but mainly by the tendency which 
it displays to the engagement of the intestinal tract in a specific 
form of secondary lesion. It is occasionally known by the term 
dothion-enterite, derived from the Greek words SoOibv, a pimple, 
and htepov, intestine, from the presence of the'pimple or pustule- 
like elevations exhibited on the mucous surface of the small in- 
testines, in the progress of the disease. This variety of fever 
has also been more recently termed " pythogenic," from 7tv9<*v, 
rotting, and ytyi/o^ou, I beget, by reason of the frequently observed, 
though by no means necessary or constant, relation between this 
class of febrile affections and such physical agencies as foul air, 
defective ventilation and sewage, and emanations from decom- 
posing animal refuse and ordure, especially human. 

Typhoid fever is essentially a disease of Continued type, in- 
sidious in its mode of invasion, extending over a period that may 
be in general defined as between three weeks and three months, 
and occasionally, and indeed under certain circumstances very 
commonly, exhibiting a division into two separate phases, with a 
well-marked interval, partially or wholly apyrexial, of one or 
more days, or it may be of one or several weeks' duration between 
them. It is in all respects a disease of a very formidable nature, 
producing lesions which profoundly impair vital organs, inducing 
organic changes of a permanent kind, and implicating life, either 
immediately or remotely, in a large number of cases. It may 
kill in the acute stage by the force of the fever exhausting the 
system, by perforation of the peritoneum and its consequences, 
by sphacelus of the intestine itself, by hemorrhage, wasting and 



170 TYPHOID. 

protracted diarrhoea, or finally by its extraordinary power of 
calling into play certain dyscrasias previously dormant in the 
system. The designation "typhoid" has been applied to this fever 
from the resemblance which it undoubtedly has in its more super- 
ficial characters to typhus. There is prostration of nervous and 
muscular power from the outset ; though hardly ever, if at all, to 
the same extent at so early a period in typhoid as in typhus ; 
there is in both the peculiar hebetudo typhosa, that state of dull, 
passive, semi-consciousness, without cerebral lesion or actual 
suspension of the mental faculties ; dorsal decubitus, semi-con- 
sciousness, more or less well-marked lividity of the skin, an 
eruption on the surface, and the typhous aspect of the face are 
present in both, yet not so strongly defined in the typhoid as in 
the typhus, nor observable at so early a period in the former as 
in the latter. Indeed in many cases of typhoid, though headache 
is present, the intellect remains undisturbed, and the patient is 
fully conscious throughout. 

Practical men cannot have failed to remark that there is a 
common expression of the face in the typhous types of disease, 
by which they can be immediately recognized ; it may be desig- 
nated the fades typhosa, and it is as well defined, and as easily 
recognizable as the fades Hiptpocralica. As we have already seen, 
the facies typhosa, and many of its accompanying symptoms, may 
be present in the following pathological states: the typhus proper, 
or maculated or Irish typhus; the typhoid, or enteric fever; the 
cholera typhoid, or that state of typhoid pyrexial action which 
so often supervenes in certain cholera epidemics after the proper 
cholera period, with its algid phenomena and diarrhoea and 
vomiting, has passed by ; the states known as typhoid pneumo- 
nia, and typhoid bronchitis ; and the more rare condition, typhoid 
pleuritis, a so-called typhoid state, which supervenes occasionally, 
in bad forms of erysipelas, measles, scarlatina, and smallpox; 
and, lastly, in certain cases, as the result of mechanical injuries, 
and as a sequel to surgical operations, typhosis becomes developed ; 
in other not well defined states also, a typhoid condition is occa- 
sionally found to supervene ; but the foregoing are those of chief 
practical importance. 

Typhoid or enteric fever commences, as we have before stated, 
insidiously ; after a period of malaise, with more or less disturb- 
ance of the intellectual energies, there may be rigors, pain in the 



GENERAL CHARACTERS OF TYPHOID. 171 

head and back, with or without gastric and intestinal symptoms. 
It is quite common, however, to find that the case progresses 
without any symptoms indicative of the mischief which is about 
to affect the abdominal organs. This is, in fact, one of the most 
deceptive features in the disease ; diarrhoea, with mucous irrita- 
tion, heat and distress in the abdomen, pain localized in such 
situations as the ileo-coecal region, with gurgling on pressure, 
and subsequently meteorism or gaseous distension of the 
abdomen, are phenomena which we should expect to find con- 
stant in cases in which there is organic lesion of the intestinal 
apparatus. It is no doubt common enough to find symptom and 
lesion associated together and progressing pari passu ; but what 
seems to be not sufficiently understood is that, in very many in- 
stances at all events, the follicular lesions will be found far in 
advance of the general symptoms, and even in certain cases the 
symptoms shall be so entirely in abeyance, that the nature of the 
case remains undetected till post-mortem examination reveal an 
advanced condition of disease in the intestines. 

The typhous state is usually developed by the fourth or fifth 
day; the fades typhosa is recognizable by this period, and so far 
it will be plain to any physician of ordinary experience that the 
case is one which falls under the typhous group, and the diagno- 
sis is narrowed to the question, whether the patient is about to 
pass through a maculated typhus, or, on the other hand, to en- 
counter the still more formidable dangers of a typhoid attack, 
and the enteric complications which follow in its train. Where 
diarrhoea, with a hot and swollen state of the abdomen, and 
anxiety, distress, or positive pain on pressure, are manifested from 
the outset of the case, or within the first week, and more espe- 
cially when this set of symptoms is unrelieved by appropriate 
treatment, but on the contrary, seems to have become more aggra- 
vated as the case progresses, the most passive observer can 
hardly fail to have his suspicions awakened, if he possesses the 
requisite knowledge of the pathology of fever. With the fades 
typhosa, the abdominal symptoms above enumerated define the 
nature of the case with almost perfect certainty, even before the 
appearance of any characteristic eruption. 

Typhoid fever, like typhus, presents so commonly a cutaneous 
eruption, that we must regard it as a main feature of the disease, 
though it is neither a necessary nor an absolutely constant one. 



172 TYPHOID. 

The period at which the eruption makes its appearance in 
typhoid is not so well defined as in typhus ; the maculae, as we 
have seen, are usually visible between the fifth and seventh day 
in typhus ; from the eighth to the twelfth day we may expect the 
eruption in typhoid. It appears in the form of rose-colored, ellip- 
tical, or lenticular spots, very sparsely disseminated on the surface 
of the abdomen, chest, neck, and rarely on the face or extremities. 
These spots, constituting the taches roses lenticulaires of the French 
authors, appear in successive crops, each lasting for about three 
days; the total period during which the eruption remains visible 
is very uncertain; it may last a week, seldom passes ten days 
from the date of its first appearance; and it is often so indistinct 
after the first two or three days that the spots are with great dif- 
ficulty recognized. 

The rose-colored spots of typhoid are readily distinguished 
from the maculae of typhus by attention to the following charac- 
ters : the rose-colored spots are extremely sparse, and may not 
exceed from a dozen to twenty on the whole anterior part of the 
trunk; it is rare that a hand's-breadth of the abdomen contains 
more than two or three of them ; in typhus the same amount of 
surface may contain a hundred maculae. The rose-colored spots 
are of more perfectly defined size and form than the maculae of 
typhus ; the latter are very variable in size, the former (the rose 
spots of typhoid) are generally about one line in their long dia- 
meter, and about half that measurement in their short axis; they 
are uniformly elevated above the surface, neither acuminated nor 
flattened on their summits ; their color is generally of a somewhat 
rosy tint, seldom if ever of the dusky and livid hue of the typhus 
maculae. Both kinds of spots disappear on pressure, reappearing 
instantly when the pressure is removed. 

In a case of fever presenting any of the phenomena of the 
typhous state (fades typhosa), the utmost caution and discretion 
must be exercised during the first week in respect to both diag- 
nosis and treatment. In the absence of characteristic abdominal 
symptoms, and before the appearance of an eruption, we are abso- 
lutely without the means of forming a logical conclusion as to the 
nature of the case. Hasty diagnosis and prognosis are liable to lead 
us into serious error at this period, if we make light of a case at the 
outset, which in a few days belies our expectations, and perhaps 
our opinions, too incautiously formed and expressed, by a fatal 



TEMPERATURE IN TYPHOID. 173 

issue from hemorrhage; perforation, sphacelus, or any of the other 
accidents for which a latent enteric lesion may be preparing the 
way. No class of cases admits so readily of being "spoiled," 
and getting perhaps a fatal tendency impressed upon it by the 
nimia diligentia medici, than a typhoid fever at the period in 
question. 

The skin usually maintains throughout a more vivid tint in 
typhoid than in typhus; it wants the clear tint of health, but 
there is not the blue and livid discoloration so characteristic of 
the maculated fever. The temperature varies with the pyrexial 
tension of the system, and in general may be considered to be 
somewhat above that of typhus by a degree or more, and below 
that of the sthenic fevers to the same extent; it averages from 
100° to 102° and 103° ; dryness of skin with calor mordax fre- 
quently are prominent features in the earlier periods; in the 
more advanced stages the skin is clammy, and it may be, ex- 
hibits a tendency to become cold. A remarkable observation is 
that now abundantly verified, of the not infrequent elevation of 
temperature in the abdominal parietes, sensible to the thermo- 
meter as well as the hand, and ranging above that of other parts 
for days in succession. This phenomenon is doubtless a direct 
exponent of the pathological conditions being developed in the 
cavity of the abdomen, to which blood is now determined in un- 
usual quantity; the observation is not devoid of practical signifi- 
cance ; and even in the absence of pain, or distress on pressure, 
or sense of internal heat and uneasiness, undue elevation of tem- 
perature in the abdominal parietes would certainly warrant the 
suspicion of impending mischief, and the use of well-directed but 
cautious means with a view to avert it. When increased heat of 
the abdomen is combined with localized undue action of the 
greater abdominal bloodvessels, as will be hereafter more fully 
noticed, no more special signs of approaching abdominal lesion 
can be desired; their significance is obvious, and upon the indi- 
cations they furnish we are not alone justified, but called on to 
attempt derivation of blood from the overloaded intestinal sur- 
faces by fomentations, poultices, leeching, pediluvia, and similar 
means. 

It may appear that we have dwelt somewhat too stronglj T on 
the tendency to latent and insidious disease in the abdomen in 
typhoid. It is no doubt more commonly the rule to find that the 



174 TYPHOID. 

specific eruptions, and the symptoms of intestinal irritation are 
developed sufficiently early to enable the well-educated physician 
to take advantage of the indications they furnish in respect to 
diagnosis and treatment. It is beyond all question, however, 
that latent cases of typhoid, so to speak, occur sufficiently often 
to render it necessary for us to exercise the utmost caution at 
the outset of all cases in which there is the slightest possibility 
that they may eventuate as typhoid, and develop intestinal 
lesion. 

Before we enter on the special pathology of typhoid fever, it 
will be necessary to establish a practical distinction amongst the 
cases that we meet with. 

(A.) The more common examples of typhoid which we meet 
with are undoubtedly those in which there is a development of 
the specific rose-colored or lenticular spots at some period between 
the eighth and twelfth day of the disease. Concurrently with 
this, and it may be even from the very outset of the fever, symp- 
toms of intestinal irritation, with abdominal heat, tenderness, pain 
on pressure, and diarrhoea more or less constant, with or without 
ileo-coecal gurgling, will have been manifested in a great number 
of instances. In such cases it is to be understood that the intes- 
tinal lesion progresses pari passu with the primary fever. 

(B.) In another variety of cases — and to this form of the disease 
I desire especially to call attention — the primary fever progresses 
for fourteen or twenty-one days, or it may be even more, with the 
development of the rose-colored rash, and all the symptoms, with 
the exception of those directly referable to the abdomen; slight 
intercurrent diarrhoea, with partial and temporary mucous irri- 
tation, may be present; but the fever progresses throughout to 
an apparent termination at the end of the third week, when the 
patient is supposed to pass into a state of final convalescence. 
Herein lies the especial danger of this class of cases. With the 
subsidence of the fever, all danger is naturally presumed to be 
at an end; the pulse falls to the natural standard, and a conva- 
lescence of the most deceptive kind ensues. Under these cir- 
cumstances the patient is perhaps discharged from hospital; if 
belonging to the laboring classes, he may resume his ordinary 
avocations ; if in military or other service, he is restored to the 
ordinary routine of his duties; and whether in civil or military 
life, in the higher or lower classes of society, he is soon re-esta- 



MINUTE INTESTINAL GLANDS. 175 

blished in the usual routine of mental or physical labor, without 
any restrictions or precautions as to diet or medicines. In fact, 
an interval now ensues which is presumed by the patient, and too 
often believed by the physician, to be the commencement of com- 
plete convalescence. But it is in reality, as will be afterwards 
seen, only a lull in the storm. 

It is not to be supposed, however, that in all instances the in- 
terval just alluded to is entirely apyrexial. By the end of the 
third week, the patient may be much relieved from the graver 
symptoms of the primary fever, without actual crisis, and he may 
remain for days, or perhaps for even a week or more, in an ill- 
defined state before any new symptoms declare themselves, and 
yet he is unable to leave either his room or his bed. This want 
of perfect, and so to say, frank convalescence after the fever has 
had time enough to work out its course in the system, is in itself 
indicative of the true nature of the case. 

We may now proceed to the detailed consideration of the lesion 
which gives to typhoid fever its most specific characters. 

Fevers of the typhoid type are constantly, though not necessarily 
or invariably, found to have associated with them a certain train 
of pathological actions, chiefly implicating the minute glandular 
apparatus of the intestines, and often more remotely engaging 
other parts. It will be useful to take a brief summary view of 
the anatomical parts concerned in these changes. 

The mucous surface presents, in its tract from the mouth to 
the anus, a minute glandular apparatus, more or less thickly stud- 
ded upon it in its various parts. However modified in the seve- 
ral sections of the intestinal tract, the minute glandular apparatus 
will be found to be readily divisible into two distinct groups, 
namely: the lenticular, and in some parts so-called follicular 
glands ; and, secondly, the glands of tubular form. As examples 
of the former or lenticular glands, otherwise known as the solitary 
glands (and when clustered in groups, as in the ileum intestine, 
called Beyer's glands, or the patches of Beyer), we may cite those 
of the mucous membrane of the mouth, known as the palatal and 
buccal glands, which are essentially the same as those of the oeso- 
phagus, and are analogous to the lenticular glands of the stomach, 
sometimes known as those of Sprott Boyd. And further, they 
differ in no essential respect from the similar glands scattered on 
the surface of the large intestines. 



176 TYPHOID. 

Examined microscopically, the lenticular glands are found to 
consist of minute closed sacs, filled with a semi-solid, granular, 
and molecular matter. Their function seems to be to fill them- 
selves gradually with this molecular matter, and when arrived 
at a state of repletion, to burst and discharge their contents upon 
the free mucous surface. The minute sac then collapses, and 
gives place to another, which performs a similar office, and in its 
turn bursts and disappears. These minute glands have been 
incorrectly described as constituting open, shallow, cup-shaped 
follicular or purse-like cavities upon the mucous surface. This, 
however, is only their more transient condition, and corresponds 
to the period after the discharge of their contents, and prior to 
their final collapse and disappearance. 

The most important examples of this kind of gland are to be 
found in the buccal, oesophageal, and lenticular gastric glands (or 
those of Sprott Boyd). In the duodenum we find the so-called 
glands of Brunner, most of which answer to the same description, 
while the solitary and aggregated glands of the small intestine 
are constructed on a similar type. In the large intestine the 
solitary glands are still present, but they lie somewhat more 
deeply imbedded in the mucous membrane, and are much less 
readily distinguished, except when in an intumescent condition 
from disease. On the mucous surface of the large intestine, there 
may constantly be noticed a number of minute dark points or 
spots, usually of a blackish color ; they resemble pin-hole perfo- 
rations, and are the apertures on the mucous surface through 
which, by a short neck, the more deeply seated little solitary 
glands discharge their contents into the cavity of the intestine. 
These minute globular glands of the colon, each with its short 
neck, have no imperfect resemblance in shape to the small bottles 
or flasks in which seltzer water is commonly sold. 

At various points of the small intestine, along its convex side, 
and therefore opposite to the attachment of the mesentery and 
the entrance of the vessels, we find the minute lenticular glands 
aggregated into masses of irregular size and shape. Under this 
form they are known by the name of the anatomist who first 
accurately described them, as the glands or patches of Peyer. 
They vary much in number, in size, and in exact position on the 
intestinal walls in" different individuals. They are rarely found 
at any higher point than about the commencement of the lower 



MINUTE INTESTINAL GLANDS. 177 

half of the ileum, and in this situation are not larger than a split 
pea. As we pass down the intestine the patches increase in size 
with some regularity ; the upper ones tend to a circular figure, 
the lower to a somewhat oval or elliptical shape. From the size 
of a fourpenny bit or that of a sixpence, they reach to half an inch, 
one inch, and in the very lowest patches to about two inches or two 
inches and a half in their long diameter, which is usually parallel 
to the long axis of the alimentary tube ; their short or transverse 
diameter is about half that of the longitudinal. One very large 
patch, of an irregularly circular shape, is often but not invariably 
found at the extreme end of the ileum intestine, and covering 
the iliac aspect of the ileo-colic valve. In examining the healthy 
intestine of the adult under forty or forty-five years of age, the 
solitary and aggregate glands of the small intestine are found in 
a condition of moderate repletion, very slightly prominent above 
the general level of the mucous surface, and not very readily 
distinguished except by a practised eye ; with the aid of a pocket 
lens, however, their position and figure can usually be well made 
out; they will be then noticed to bulge slightly through the 
mucous surface, being here and there studded with intestinal 
villi. The part which this minute glandular apparatus performs 
in the general economy of the alimentary tract is far from well 
defined. No share in the office of nutrient absorption seems 
readily assignable to them, and it is not improbable that they 
subserve an excretory function, by removing the waste elements, 
and effete materials of the intestinal mucous membrane, thus 
assisting to maintain it in the state of health. There is some 
reason to believe that the physiological activity of this minute 
glandular apparatus becomes somewhat impaired as the individual 
advances in life. After the forty -fifth year, or thereabouts, the 
solitary glands and the patches of Peyer are found in a condition 
of more or less marked degeneration ; they no longer present to 
the naked eye or the magnifying lens that state of fulness and 
repletion of the individual glandules, whether in the solitary form 
or in the aggregated patches which we notice in them in earlier 
life ; the patches are shallow, thin, often bloodless, and having 
somewhat of a reticulated appearance, due to the evacuation of 
the contents of the individual follicles. It is manifest that the 
period of physiological activity is passed, and with the decline 
of their physiological activity in a great measure ceases their 
12 



178 TYPHOID. 

power of participating in diseased processes. Hence it is, in all 
probability, that the ulcerative and other lesions of the intestines 
are comparatively rare in the fevers of persons in advanced life. 
It even admits of question, whether it is possible that typhoid 
fever can occur in association with the special intestinal lesions 
we are about to consider in persons past forty-five or fifty years 
of age. Clinical experience corresponds with the indications of 
physiology in this respect, for no well verified examples of 
typhoid fever, in persons over fifty years of age, are found on 
record. It is, of course, quite possible that the period of physio- 
logical activity of the intestinal glands may be continued to a 
more advanced period of life in individual cases, and then the 
period of liability to pathological lesion may be expected to be 
proportionately prolonged. 

The second important variety of the mucous glands of the 
intestine are those first described by the celebrated Lieberkuhn, 
and still known somewhat incorrectly as the follicles of Lieber- 
kuhn. It is now well known, however, that the glands in ques- 
tion, instead of being superficial cup-shaped depressions on the 
mucous membrane, consist of tubular prolongations, striking off 
nearly at right angles from the mucous surface, and penetrating 
to the depth of one or two lines. These tubular glands run a 
somewhat straight course, and remain undivided, throwing off 
no branches in the human subject; in other animals, as the dog, 
they are found branched, clustered, and constituting the glande 
en grappe, in which the primary glandular tubule throws off a 
number of minute stems, each with a little saccular termination, 
the whole mass resembling a cluster of grapes hanging by a com- 
mon stem. 

The tubes of Lieberkuhn are found disseminated through the 
small and large intestines, but as they participate but little, and 
that only indirectly, in the pathological changes we are about to 
consider, it will not be necessary to pursue their consideration 
further. 

We may here recapitulate, for clearness sake, the various forms 
of glandular apparatus recognizable in the mucous membrane. 
We may enumerate : — 

In the Stomach. 
1. The gastric glands of tubular shape. 



MINUTE INTESTINAL GLANDS. 179 

2. The gastric glands of lenticular shape, constituting minute 
shut sacs. 

In the Duodenum. 

The glands of Brunner, chiefly shut sacs, but some of them 
tubular and grape-like. 

In the Small Intestines. 

1. The (so-called) follicles of Lieberkuhn, consisting of tubular 
prolongations lined with epithelium, usually straight in the human 
subject, and unbranched. 

2. The lenticular solitary glands, constituting shut sacs. 

3. The Patches of Peyer, or the agminated glands, and consist- 
ing of more or less clearly defined groups or clusters of solitary 
follicles, identical with those last described. 

In the Large Intestines. 

1. The (so-called) Lieberkuhn follicles. 

2. The solitary lenticular-shaped follicles. 

It is only under certain conditions of disease that we find the 
glandular apparatus of the intestines thrown so prominently into 
relief as to enable us to recognize them on superficial inspection 
of the intestines. The pathological state which accompanies 
Asiatic cholera is that which, in my experience, best demon- 
strates the solitary and aggregate follicles. In this disease the 
mucous membrane is literally washed, by the copious serous exu- 
dations which take place from its surface, to a state of cleanness 
and purity such as it would be impossible to effect by any arti- 
ficial process without entire destruction of the epithelial layer. 
There is usually present a more or less vivid rose-pink colored 
vascularity of the whole, or greater part of the intestinal tract ; 
upon this rose-colored surface we find scattered, as it were, a 
number of minute rounded granules, occasionally of a milk white, 
oftener of a dirty cream color, and thus forcibly contrasting with 
the rose-colored ground upon which they seem disseminated ; 
the whole has the appearance of a pink surface with a number 
of small whitish bodies, such as sago grains, thickly strewn upon 
it, and here and there aggregated into thick close clusters of an 
inch or more in diameter. The pathological state present is that 



180 TYPHOID. 

of infarction of the solitary and aggregated glands, with, a creamy 
exudation ; and this I have myself ventured to designate as the 
sago-grain condition of the intestinal glands in cholera. 

In other states, likewise, as in the so-called Follicular Enteritis, 
and in the typhoid states presently to be considered, we find the 
solitary and aggregate glands very prominent above the surface ; 
but the general coloration is of almost uniform character, and 
they are consequently not so strikingly visible as when filled 
with a whitish or cream-colored exudation, which as we have 
just noticed is the case in cholera. 

The solitary and aggregated glands (patches of Peyer) are, as 
we before intimated, those chiefly and primarily engaged in the 
typhoid lesions. Eokitansky, who has studied and developed the 
pathology of this lesion with his usual profoundness, recognizes 
four distinct periods or stages in the follicular lesion, to which my 
experience warrants me in adding three more. 

1. The congestive stage. 

2. The stage of typhoid infiltration, or stage of crude deposit. 

3. The stage of softening and rejection of the typhoid matter. 

4. The stage of genuine typhoid ulceration, with or without its 
direct consequences, such as perforation, peritonitis, &c. 

5. The stage of sphacelus of one or more of the patches of 
Peyer. 

6. The stage of healing of the typhoid ulcer, in which a pro- 
cess of cicatrization is established, and which is the most impor- 
tant, as it is the most favorable of the conditions which may 
ensue after the evacuation of the typhoid matter. 

7. In cases not fatal from typhoid in the early periods, a slow 
process of atrophy of the intestines is sometimes brought about, 
with thinning and wasting of the mucous tissue, filling up and 
final disappearance of the tubes of Lieberkuhn, and the produc- 
tion in the end of a kind of parchment like state of the mucous 
membrane, in which it has lost many of its physiological proper- 
ties, and its vessels and glands are no longer able to carry on the 
process of alimentation except in the most incomplete and im- 
perfect manner. In such cases, the patients live on sometimes 
for a considerable period of time, becoming gradually more and 
more worn and emaciated, with dry and furfuraceous (branny) 
skin ; tubercular and other dyscrasic states are induced in the 



GENEKAL ABDOMINAL CONGESTION. 181 

end, and the patient finally sinks a victim to cachectic disease, in- 
vading almost all the tissues and organs of his body. 

We shall now proceed to study the several conditions just 
enumerated, taking them first in their anatomico-pathological re- 
lations, and then endeavoring to develop the various clinical 
characters by which they may be recognized during life. 

When opportunity offers for post-mortem examination of cases 
of typhoid fatal during the congestive stage, we find an increase 
of vascularity often amounting to great congestion in the general 
peritoneal surface, on the exterior of the small intestines, in the 
mesentery, occasionally in the omentum, and in the spleen. 

There is often a state of great intestinal congestion, to the 
extent of producing a uniform bluish black discoloration of the 
small intestines, sometimes extending throughout their entire 
tract, and manifesting itself on both the serous and the mucous 
surfaces. That there is a large excess of blood determined to the 
abdominal organs and the jejunum and ileum intestines especially, 
in these cases, is unquestionable. 

Extensive congestion of the mesentery and mesenteric glands, 
is likewise often noticed ; the glands are apparently swollen, and 
on section exude dark venous blood in large quantity. 

On the internal aspect of the intestines we may observe a simi- 
lar state of general intense vascularity ; in some instances the 
whole mucous surface is of a deep bluish red tint. In other 
instances we may note patches of vascularity specially determined 
to the site of particular sets of the solitary follicles and the agmi- 
nated glands. Thus in some places arborescent vascular rings will 
be found to surround independent solitary follicles; in other 
parts larger vascular rings will be observed to embrace a group 
of Peyer's glands, throwing a vascular network into and through 
and across the patches. Occasionally large irregular oblong 
patches of vascularity will be found to occur in parts of the in- 
testine next the seat of Peyer's glands ; they may embrace a 
couple of inches or more of the intestine, and are the result of 
determination of blood to the included group of solitary follicles. 

We find abundant evidence in these cases of an excessive de- 
termination of blood to the intestinal surfaces, and also to the 
peritoneal cavity generally. It is also the states last described 
which are the result of an active hyperemia, and which are effec- 
tive in the production of the further changes in the glandular 



182 TYPHOID. 

apparatus of the alimentary canal. The sensations of heat and 
distress in the abdomen, with, not infrequently, excessive action 
of the abdominal aorta, presented during life, may be supposed to 
accompany the states of congestion and hyperemia above de- 
scribed. And we are here furnished with indications both for 
derivative measures, such as leeching, poulticing, and warm fo- 
mentations to the abdomen, and for the qucedam vitanda, including 
the use of purgatives, and stimulant or irritating aliments of all 
kinds. 

The stage of congestion is naturally followed by that of typhoid 
infiltration of the glandular apparatus. The period at which in- 
filtration of the minute glands of the intestine supervenes is not 
well defined. It appears to occur oftenest within the first week 
or ten days from the outset of the fever ; but it may take place at 
a much later stage. When the infiltration has advanced to a 
certain extent, we observe the solitary and agminate glands 
(patches of Peyer) to bulge more or less prominently above the 
general surface of the intestine, having at the same time a dark, 
occasionally reddish, aspect. The amount of infiltration, and its 
consistence and color, vary much in different cases. Thus we may 
find the solitary glands here and there from half a line to a line 
in diameter, almost the size of small shot ; in other instances, or 
perhaps in other parts of the intestine in the same case, they are 
of the size of small peas ; and as an example of extreme infarction, 
we occasionally meet with cases in which several of the solitary 
glands will be of the dimensions of a moderate sized bean. The 
patches of Peyer are usually correspondingly affected, and present 
themselves as oval elevated masses of variable thickness — one- 
sixteenth, one-eighth, or even one-quarter of an inch above the 
level of the contiguous membrane. The following case well ex- 
emplifies the conditions just referred to. The patient, a soldier 
in the army of the East during the late Crimean war, had had 
what was described as " a short fever ;" this was succeeded by a 
second febrile attack, which terminated fatally by the eighth or 
ninth day. The intestines were found deeply congested, and, 
together with the mesentery, presented a general bluish-red color. 
The ileum was chiefly engaged, and more especially in its lower 
half. Some of the upper solitary and agminate glands were a 
little prominent and swollen. These characters became gradually 
more developed towards the termination of the ileum ; in the 



NATURE OF MASSA TYPHOSA. 183 

lower third the solitary glands were immensely enlarged, very 
prominent above the surface, conical in shape, and many of them 
as large as the biggest peas, being of a mixed reddish and yellow- 
ish color. The lower patches of Peyer were from an eighth to a 
quarter of an inch prominent, of a deep brown red color, and 
their individual glandular were much swollen ; some of the glands 
of the colon likewise were engaged. On section the tumid folli- 
cles of the ileum presented the same mixed reddish and yellowish 
color ; their contents were of pretty firm consistence, and nowhere 
showed any commencement of a softening process. The mesen- 
teric glands were greatly enlarged, some to the size of kidney 
beans, and deeply congested, freely exuding dark blood on section. 

This may perhaps be looked upon as an extreme case of glan- 
dular infarction with the secondary typhoid deposit, proving fatal 
from the impression on the system made by the pyrexia itself, 
and before any effort had been set up to eliminate the deposit; 
consequently no eliminative action was to be looked for, nor did 
any such exist. It is of course not to be expected that the de- 
posit ordinarily exists to the extent above described. 

The nature of the typhoid deposit, the so-called massa typhosa, 
has been the subject of much discussion amongst pathologists. 
Its microscopic characters, however, prove it to be an exudation 
of extremely low type, and entirely incapable of undergoing any 
process of cell-formation. Under a high magnifying power the 
typhoid deposit is seen to present innumerable minute molecules 
and granules, and some bodies having the appearance of imper- 
fectly developed nuclei. 

It is extremely difficult, if not impossible, to define with pre- 
cision the periods during which the state of intumescence and 
typhoid infarction of the minute glandular apparatus of the in- 
testines may exist without proceeding to ulceration. I have had 
opportunities of observing remarkable cases, in which complex 
processes of disease seem to have extended over several months 
without the typhoid deposit undergoing evacuation, and without 
any ulcerative action being set up in the intestines. In one in- 
stance, 1 in which sudden death took place from the rupture of an 
aneurism, towards the end of the second month from the first 
attack of fever, Peyer's patches were found remarkably tumefied, 

1 See Report (Blue Book) on Diseases of the Army of the East, p. 81. 



181 TYPHOID. 

but the deposit was not uniformly disseminated through the in- 
dividual gland patches. Thus towards its extremities, and in 
irregular little masses in its centre, a patch would be found to 
present groups of its individual gland vesicles excessively dis- 
tended with milky contents. Other portions of the same patch 
were found completely bare, numerous little vesicular cavities 
seeming empty and collapsed. 

Protracted duration of deposit without ulceration. — Death has not 
infrequently occurred at advanced but very variable periods after 
the primary fever, in cases which on post-mortem examination 
have been found to show a still comparatively early and imma- 
ture condition of the secondary deposit. In this class of cases I 
have generally found the morbid appearances to be chiefly con- 
fined to the ileum, and most commonly the lower part only of 
this intestine was engaged ; more or less extensive congestion of 
a dark livid color existing throughout the mucous membrane of 
this intestine, and being visible both on the peritoneal and the 
mucous surfaces. The solitary follicles and the patches of Peyer 
were found in a state of active turgescence, partly from exudation 
into the follicles, and partly from much increased vascularity in 
and around individual follicles and patches. The infiltration in 
this kind of case was found to vary a good deal in appearance ; 
it was sometimes of a creamy or dirty whitish color, while in 
other instances it was of a dark brownish tint. In this stage it 
was generally pretty consistent, and showed no disposition to 
soften or break up; consequently no traces of ulceration were 
anywhere visible. The deposit was found on examination under 
the microscope to consist of minute imperfect cells or nuclei, with 
granular and molecular matter in large proportion. 

We have met with not a few instances in which the follicular 
glands of the colon participated in the condition presented by 
those of the ileum. The mucous surface of this intestine has 
been found dotted over in a very remarkable manner with the 
minute dark orifices leading to the solitary vesicular glands. 
For the most part these little organs were in a state of intume- 
scence, felt hard under the finger, and on microscopic examina- 
tion were found to be filled with an exudation consisting chiefly 
of very fine minute imperfect cells and granular matter. 

There is reason to believe that in many of these cases the 
typhoid action had been pretty generally diffused in the system. 



TYPHOID DEPOSIT IN LUNGS. 185 

though it had not advanced in what may be termed its seat of 
election, namely, the follicular glandular apparatus of the intes- 
tine, to a very marked degree. Thus though the deposit in the 
solitary and aggregate glands had not proceeded beyond the con- 
ditions of infarction and intumescence just noticed, we have in 
many instances found typhfoid deposit to a considerable extent in 
the mesenteric glands, the spleen, the kidneys, and in some in- 
stances in the lungs. 

Other secondary lesions in cases with non-ulceraiive deposit. Me- 
senteric glands. — Enlargement of the mesenteric glands, as will be 
subsequently noticed, is so commonly found on a post-mortem 
examination in typhoid cases, that it is deprived of at least some 
of the pathological interest it might otherwise have in these cases. 
In typhoid cases in general it may be said these glands are inva- 
riably enlarged ; sometimes they are increased in size to three or 
four times their ordinary volume. They are usually deeply 
injected, highly vascular on section, and occasionally softened 
within. 

Spleen. — In some few instances of the class of cases now under 
consideration (infarction of the follicular intestinal glands, but 
without ulceration), deposit has been found in the spleen. More 
commonly in this stage the changes in this viscus have been con- 
fined to enlargement and increased vascularity, with a deep mul- 
berry tint, and pulpy consistence of its texture. 

Kidneys. — In the kidneys, increase in size and vascularity, with 
friability of the renal texture, has been commonly produced, even 
thus early. 

Lungs. — In the thorax, engorgement, with friability of the sub- 
stance of the lungs, extensive bronchial affections, and sometimes 
actual exudation into the pulmonary texture, have accompanied 
the intumescent and non-ulcerative state of the solitary and 
aggregate glands of the intestine. 

In these cases, the exudation into the lung has been very dif- 
ferent in character from that of ordinary inflammatory origin. 
It has been soft, sometimes of a dirty, half gelatinous, half 
grumous, material. There has been no uniform condensation of 
any of the lobes. The pulmonic texture exhibited in some places 
a sanguineous engorgement, with general infiltration of a bloody 
serum. In other cases the anterior aspect of both lungs on 
section exhibited deposits of exudation, the site of which was 



186 TYPHOID. 

indicated on the surface of the pleurae by considerable opacity of 
the membrane. In the neighboring tissue, in such instances, 
portions of the exuded material seemed to be passing into a 
gangrenous state; in other parts pus like exudations were here 
and there diffused throughout the substance of the lung. In 
other but somewhat similar cases, considerable pleuritic effusion 
existed on one or both sides. In other parts, imperfect exuda- 
tions, as already noticed, were to be found; but, neither in any 
one case, nor in a series of cases, does the pulmonary complica- 
tion in either or both lungs, or even in contiguous parts of the 
same lung, usually present any uniformity of character, or any- 
thing well defined either in its nature or extent. Ill-defined 
pleural exudations of low type have likewise been found, usually 
connected with some of the forms of pulmonic engorgement just 
mentioned. So far the absence of special character lends sup- 
port to the view which associates the pulmonic lesion in these 
cases with the other secondary diseased processes due to the 
typhoid dyscrasis. 

Elimination of the deposit without ulceratidn. — "We have seen that 
cases of typhoid fever may be immediately fatal during the pri- 
mary pyrexial attack, from the violence and profoundness of the 
impression made on the system. We have also seen that, when 
so fatal, there may be deposit to a very large extent in the soli- 
tary and aggregated follicles. 

Supposing the case to survive the first period of the fever ; and 
that the patient is progressing with symptoms that warrant us in 
believing that deposit has already taken place in the glands of 
the intestine, it now becomes a question of the most vital moment 
to ask what are the possible ultimate issues of such a case ? The 
more common tendency observable in such cases is doubtless 
towards softening of the deposit, and elimination of the contents 
of the follicles, with the supervention of an ulcerative process 
which attacks the site of the follicles and patches. Ulcerative 
action under such circumstances brings in its train dangers of the 
most formidable kind, including perforation of the peritoneum, 
and death from peritonitis, erosion of a bloodvessel and death 
from hemorrhage, protracted suffering from wasting diarrhoea 
and abdominal pains, and death after a longer or shorter period 
when the patient is in the last stage of marasmus. 

Now it may be asked, when typhoid deposit has once taken 



ELIMINATION OF DEPOSIT WITHOUT ULCEKATION. 187 

place in the glandular apparatus of the intestines, can we look to 
any other means than ulceration for its elimination? I believe 
we shall be warranted in answering this question in the affirma- 
tive, with the necessary restriction, however, that unfortunately 
the mode of termination we are about to speak of cannot be con- 
sidered a very usual one. It may, however, admit of very rea- 
sonable doubt whether such a termination may not possibly be 
more frequent when the pathology, dietetics, and therapeutics of 
typhoid fever are more generally understood. 

In the course of very extensive pathological investigations, I 
have had occasion to observe not a few instances in which elimi- 
nation of the typhoid deposit seemed to have taken place en- 
tirely independently of ulcerative action. Thus the minute 
glands and patches of Peyer have been observed in a state of 
partial intumescence, the deposit being, when it still remained, of 
a dirty milky or somewhat creamy aspect and consistence. Parts 
of a patch exhibited its glandular vesicles empty and collapsed, 
while here and there other vesicles contained the deposit in the 
semi-liquefied state just mentioned ; melanotic spotting of the 
patch was noticeable in other parts, and when present, this ap- 
pearance is at least presumptive evidence of previously existing 
morbid vascularity. When the deposit has been for a time un- 
dergoing a softening and liquefying process, we can readily 
understand how it may escape and be eliminated by bursting of 
the vesicles, which subsequently collapse and assume the appear- 
ance of little shallow pits (very much like the aggregation of the 
minute depressions punched on the end of a thimble), and which 
give rise to the so-called " reticulated appearance 1 ' of the patches 
of Peyer. When the deposit is brought to a suitable state by 
this process of liquefaction, the ordinary peristaltic action of the 
intestines, with the contractions of the muscular coat in successive 
rings, no doubt much assists the eliminative action by causing 
rupture of the vesicles. Lastly, it may be stated that, in well- 
marked cases of partial evacuation of the typhoid deposit, the 
most minute examination of the intestinal surface showed the 
total absence of any trace of ulcerative action. 

The applications of these pathological results to practice are 
important and obvious. We are here furnished with clear indi- 
cations for endeavoring to promote derivation of blood from 
the mucous surface, for keeping the intestines in as quiescent a 



188 TYPHOID. 

condition as possible, and in respect to dietetics for avoiding the 
use of all but the mildest, and most bland, and the most readily- 
assimilable and absorbable foods. 

Stage of ulceration; Elimination of deposit by ulceration. — The 
next class of cases embraces those in which actual ulceration of 
the intestines has been established. The precise period requisite 
for the full development of the ulcerative process does not, as we 
have seen, admit of being definitely determined, and is probably- 
very variable in different cases ; it is possible that no two cases 
of the disease are alike in this respect. We have endeavored 
to show that ulceration is not by any means a necessary or in- 
variable consequence of deposit, even when very extensive and 
persistent for a great length of time. On the other hand, the 
typhoid matter seems in some instances to be capable of exciting 
inflammatory reaction, as it were, with extraordinary violence 
and at a very early period, and in some cases with the produc- 
tion of actual sphacelus of the parts implicated. 

Deposit in the glands, with inflammation proceeding to sphacelus. — 
In the following cases the very advanced condition will be found 
to have taken place, in which the eliminative and ulcerative pro- 
cess was superseded by complete sphacelus, with entire destruc- 
tion of the glandular textures and the intestinal walls. 

I have already partially alluded to a case of the most remark- 
able kind, in which death took place on or about the tenth day 
after admission into hospital, and in all probability within twelve 
or at the utmost fourteen days from the first invasion of the dis- 
ease. The principal effects of the morbid process were found in 
the abdominal cavity; throughout the ileum the most extensive 
ulceration of Feyer's patches existed, in some with total destruc- 
tion of all the tissues of the intestines. In two or three of the 
lowest of the patches the sphacelus of the tissues was so com- 
plete, that after opening the intestine, the ash-colored sloughs 
corresponding to the mortified gland patches became detached 
and fell out, long oval apertures being left in their site. Perfora- 
tion had occurred (probably two or three days before death), and 
extensive peritonitis existed, the viscera being glued together by 
recent lymph. It is worth noticing the statement furnished in 
connection with the clinical history of this case, to the effect that 
the bowels were regular, and that there was no complaint of pain 
in the abdomen till within two or three days before death. In 



CHAKACTEKS OF TYPHOID ENTERIC ULCERS. 189 

some few other cases I have had opportunities of witnessing this 
intense destructive process in the tissue of the aggregate glands, 
but it was usually the result of a much more chronic process of 
disease. 1 

Enteric ulcers. — A well-marked illustration of the chief morbid 
phenomena of ulcerative typhoid is presented in the following 
case, which occurred in the Crimea in the month of August, 
1855. The patient was admitted on the 2d, and died on the 
16th. Diarrhoea was present from the first, and continued through- 
out; there were also much vomiting, and much nervous irrita- 
bility, attended towards the close with violent and almost constant 
subsultus tendinum ; pain and gurgling were observed in the 
ileo-caecal region, and bed-sores had become established already. 
On post-mortem examination general enlargement, prominence, 
and turgescence, with frequent ulceration of the solitary glands 
of the intestine, were found; there was also most extensive 
ulceration of Peyer's patches. The mesenteric glands were en- 
larged and much congested. 

The particulars of another case are worthy of being specified. 
The patient (a soldier in the Crimea) had had a short febrile 
attack of seven or eight days' duration, from which he convalesced 
sufficiently to enable him to leave hospital and return to duty ; 
but it was found necessary to readmit him in three or four days 
subsequently, when fever of a low type became developed. It 
is stated that he had bloody stools on admission, and about the 
tenth, eleventh, and twelfth days of his illness he was affected 
with diarrhoea, but without the least attempt at crisis. Thence- 
forward in the disease this symptom, though occasionally present, 
was not constant or marked, nor does it appear that there were 
any other symptoms of a kind to draw attention to the abdominal 
region. A very extensive bronchitic affection became developed 
subsequently, which assumed a very formidable character, and 
was in all probability the more direct cause of death, which 
occurred about the twenty-fifth day from the date of the second 
admission of the patient into hospital : bed-sores had formed in 
this case likewise previous to death. 

1 Specimens of the sphacelated typhoid intestine may be inspected in the 
museum of Fort Pitt, Chatham, and in that of the medical school of the Catho- 
lic University of Ireland, Dublin. 



190 TYPHOID. 

On post-mortem examination, circumscribed pleuritis with re- 
cent lymphy exudation was found in both pleural cavities. The 
bronchial tubes were filled with copious viscid secretions extend- 
ing throughout their minutest branches. Intense congestion was 
found in the abdominal cavity, both in the omentum and mesen- 
tery, and on the serous surfaces of the alimentary canal. The 
small intestines were deeply congested, in several places greatly 
contracted and presenting a quadrangular form, and in some 
points diminished to fully one-fourth of their natural calibre. 

The ileum was much congested, and exhibited numerous deeply- 
eroded ulcerations, chiefly corresponding to Peyer's patches, which 
were completely eaten away down to the muscular coat. This 
was most remarkably the case in the last three or four patches, 
the erosion being complete down to the muscular structures, 
which lay bare, red and dry ; the borders of these ulcerations 
were thick, and in some parts elevated, being also generally ex- 
tremely angular and irregular. There were besides several minor 
erosions, corresponding to the site of the solitary glands ; the in- 
tervening mucous membrane was thickened and of a dark bluish 
red tint. In the colon, numerous but more regular oval -shaped 
ulcerations were found, the mucous surface running flush to the 
edge of the ulcer. Towards the sigmoid flexure there was some 
evidence of a dysenteric process. The mesenteric glands were 
much enlarged, and many of them had undergone a process of 
cheesy softening. The kidneys, spleen, and liver were somewhat 
enlarged and congested, but presented no characteristic change. 

These cases, few but well-marked as they are, will serve as a 
type of those which are not infrequently to be met with when the 
disease advances rapidly. It is necessary, however, to remind 
the reader that such changes must not be ordinarily expected at 
an early period of the fever. It is probable that the deposit in 
the follicular apparatus of the intestines occurs chiefly during the 
primary stages of the disease. But the changes connected with 
its elimination, and the consequent processes of ulceration, are 
not set up till a subsequent period. The occurrence of these 
changes is often more or less distinctly separated by an interval 
of time and of partial convalescence from the primary attack. A 
distinct re-establishment of febrile symptoms, with or without 
diarrhoea, and occasionally with abdominal pains and tenderness, 



CHARACTERS OF TYPHOID ENTERIC ULCERS. 191 

seems to indicate and to be connected with the immediate occur- 
rence of this ulcerative process. 

We have already seen in the above example an instance of 
the most destructive ulceration, in some parts proceeding to actual 
sphacelus, which yet was known to have progressed to this con- 
dition within from twelve to fourteen days. On the other hand 
our tables furnish us with cases in which, from the symptoms 
during life — the passing of blood, and the persistence of tarry 
evacuations per anum — it is probable that the ulcerative process 
was in operation for many weeks, and in some instances for many 
months. In these cases, even when they had become very chronic, 
extensive dark and bluish red congestion was found to exist 
throughout the abdominal cavity, more especially observable, 
however, in the small intestines and their mesenteric appendages. 
In the ileum this condition was observable as well on the serous 
as on the mucous aspect. The ulcerative process was often found 
to engage both the solitary and the aggregate glands indiscrimi- 
nately ; its point of election, however, seemed to be the lower 
patches of Peyer. Thus, advanced ulcerations have been found 
in the large patch close to the ileo-colic valve, while the solitary 
and aggregate glands in the upper portions of the intestine were 
still intact. 

The typhoid ulcerations of course vary much in amount, in 
number, in the extent of destruction of tissue they have caused, 
in the characters of their base and of their edges, whether thick- 
ened, or sharp, or ragged, in their color, whether ashy, sloughlike, 
or of a red and irritable appearance, and in the intensity of the 
vascular action in their immediate neighborhood, and in several 
other characters. The extent of the individual ulcerations like- 
wise varies much; they seldom have definite shapes. Most 
frequently, perhaps, they exhibit an irregularly oval outline, 
varying from quarter, or half an inch ; to an inch and a quarter, 
sometimes more, in the long axis of the ulcer, and quarter, half, 
to three-quarters of an inch in their shorter axis. The long axis 
of the typhoid ulcer is usually in the direction of that of the patch 
of Peyer involved, and therefore coincident, with that of the in- 
testine. The most regular inform are those which present raised 
and thickened borders; they are somewhat circular and of the 
size of a shilling:. 

Two chief subdivisions may be made of the enteric ulcer : lstly. 



192 TYPHOID. 

Those with sharp well defined process, ragged borders, more or 
less deep base, and in which the erosive process seems still to be 
in active operation ; and, 2dly. Those in which the edges are 
thickened and rounded, their borders elevated, sometimes into 
fungating masses, and the base more or less filled in ; these may 
be designated the circumvallate ulcers. 

The final issue of the process of ulceration, which seems natu- 
rally to tend in almost all cases towards perforation of the intes- 
tine, is generally anticipated by the death of the patient, hastened 
in many instances, doubtless, by the coexistent pulmonic and 
other visceral complications. But considering the number of 
cases which I have had an opportunity of examining, I think it 
may be said that complete destruction of the tissues of the intes- 
tine to intestinal perforation is not so common as is often supposed. 

Healing process in enteric fevers. — The patches of Peyer have 
been found by me and Dr. Aitken, in some few instances, in a 
state indicating an attempt to establish a healing process. The 
ulcers are usually of brown color, with extensive congestion 
around their margins ; in the centre of the patch a small circular 
space will occasionally be noticed, showing the remains of an 
apparently healed ulcer ; it will be seen to be covered over with 
a thin clear membrane, of pale color, semi-transparent, and with. 
a wrinkled and somewhat contracted border. These signs are, 
however, of not very usual occurrence, and care must be taken 
not to confound with them the ash-gray colored slough often to 
be noticed at the bottom of enteric ulcers in an advanced condi- 
tion. 

Typhoid lesion in colon. — Evidences of the extension of the 
typhoid process to the colon are sufficiently often observable. 
As already noticed, the solitary follicles of the large intestines 
are often found tumid with exudation ; in still more advanced 
cases, chiefly associated with the similar condition in the ileum, 
more or less extensive ulcerations have been seen in the site of 
these glands. When least abundant, typhoid ulcerations of the 
large intestines are more commonly to be found in and about the 
caecum ; whereas, it must be remembered, that in the dysenteric 
process, the seat of election of the diseased action seems to be in 
the lower portion of the great intestine. I have generally found 
that, when of limited extent, both the exudative and the ulcera- 



TYPHOID LESIONS IN OTHER ORGANS. 193 

tive processes in dysentery are generally confined to the sigmoid 
flexure of the colon and the upper part of the rectum. 

Other secondary lesions. — While in the cases of glandular in- 
tumescence of the intestines without ulceration, we have not 
infrequently met with lesions of a typhoid character in the viscera 
of the abdomen and the thorax, it may be stated that in the cases in 
which the enteric lesion has proceeded to actual ulceration, almost 
no instance will be found in which, on post-mortem examination, 
more or less extensive affections of some, and often of all these 
parts, do not exist. Thus lesions of the mesenteric glands, the 
spleen, the kidneys, and the lungs, may be said to be constant, 
while the liver also is sometimes engaged. Affections of the 
peritoneum, from the condition of circumscribed inflammation, 
limited to the immediate neighborhood of an ulceration which 
had approached to, but not perforated, the serous membrane, to 
that of general sero-purulent effusion with exudation of recent 
lymph, have also been met with. But these must be regarded in 
the light of accidental, not of necessary occurrences. Actual 
perforation of the serous membrane has, however, not been so 
commonly found by me in proportion to the number of cases in 
which extensive ulceration existed, as is generally thought to be 
the case. Tn some rare instances, the morbid action, set up by 
the ulcerative process, has been found to engage the areolar tissue 
near the caput cascum, resulting in one marked case which fell 
under my observation, in the establishment of pericecal abscess 
(the perityphlitis of authors). In this case the ileum presented, 
scattered over its surface, numerous small points of ulceration, 
about one-sixteenth of an inch in diameter, with a depressed 
centre, and surrounded by a deeply-congested vascular ring: these 
ulcers increased in size and frequency towards the ccecum. Ex- 
tending from the vermiform process to about the middle of the 
ascending colon, there was found behind and around the caecum 
a large abscess filled with fetid gramous pus. 

The numerical results obtained by Louis are interesting in re- 
spect to the engagement of the follicles of the colon in typhoid. 
In the second week of the fever he has found the follicles of the 
colon engaged in two instances out of fourteen cases, in the third 
week in six cases out of t wen ty- three, in the fourth week in four 
cases out of fifteen, and between the fifth and tenth week in 
13 



191 TYPHOID. 

seven cases out of eleven, or in nearly one out of every two 
cases. 

In certain advanced cases, the typhoid enteric lesion will be 
found to be associated with more or less extensive dysenteric 
processes. As far as post-mortem appearances go, the dysenteric 
process found present in these instances may be said to be only 
an additional morbid state superadded to the several other co- 
existent lesions of a secondary kind ; for the thoracic and abdomi- 
nal complications are almost invariably present in the same order 
of morbid association, and to the same extent as in the class of 
cases last considered. The extent to which the dysenteric lesion 
existed was, in some cases which fell under my notice, extreme; the 
mucous membrane of the large intestine was found covered thickly 
with large and deeply-excavating ulcers of a greenish-black hue; 
the ulcerative process largely engaged the rectum in these cases. 
In some instances traces of the characteristic diphtheritic exuda- 
tion still remained ; ulceration, though extensive, was sometimes 
confined to the lower part of the sigmoid flexure ; and it may be 
generally stated, that when a limited amount of ulceration was 
present, its most common seat was in the sigmoid flexure, or in 
the upper part of the rectum. This corresponds with what we 
know generally of the anatomical habitat of dysentery, and may 
so far be used (should any doubt arise on the subject) to identify 
the nature of the process now under consideration, as found asso- 
ciated with the typhoid state. It is possible that under some 
circumstances these appearances admit of the interpretation that 
they are the remains of a dysenteric attack antecedent to the 
invasion of the fever. 

With regard to these various secondary lesions found associated 
with actual ulceration of the intestines, it may be said that they 
differ in no respect except in degree and amount from those we 
have already described in connection with the intumescent but 
non-ulcerated state of the solitary and aggregate glands. 

Cranium. — The cranial cavity has been frequently examined 
by me in typhoid cases. In the advanced stages of the disease, 
more or less extensive congestions of all the membranes of the 
brain have been met with, but there has been a total absence of 
any special or characteristic changes. Atrophic states of the 
brain have been observed in chronic cases of a complicated kind. 

Thorax. — It will hardly be necessary, with reference to the 



TYPHOID LUNG INFILTRATIONS. 195 

thoracic complications, to do more than state that they are very 
constantly present, and will be found to be similar to the condi- 
tions hereafter described. Extreme turgidity and congestion of 
the bronchial membrane, very frequently associated with ca- 
pillary bronchitis, general engorgement of the pulmonary sub- 
stance, more or less extensive lobular exudations and condensation 
of tissue, and various changes to purulent transformations in the 
exuded matter, are constantly presented, and seldom in an isolated 
form. Pleural effusions, and occasionally circumscribed pleural 
exudations, are to be met with in connection with these changes. 

Lung infiltrations. — Infiltration of the pulmonary tissue by 
semi-transparent gelatinous exudation, taking somewhat the form 
of a miliary deposit, is often to be observed. This form of the 
deposit has generally resulted (1) from its having been exuded 
into the terminal air vesicles, or (2) because it was deposited in 
that form as an interstitial exudation. In the first form, the de- 
posit for the most part consists of altered epithelial secretion, as 
in prolonged dysenteric cases, or in those in which the typhoid 
state has long existed; irregular, withered, collapsed, and com- 
pressed cells constitute the chief microscopic elements. 

Softening and friability of the pulmonary texture is a very 
constant post-mortem state in protracted cases of typhoid fever ; 
it is sometimes associated with exudation as a marked and well- 
defined deposit. 

Typhoid consolidations. — In the condensation of the lung from 
pneumonic exudation, the pulmonary artery is generally filled 
with a fibrinous coagulum, extending through the minuter sub- 
divisions of this vessel. This state is sometimes obvious only in 
the immediate neighborhood of a condensed part. 

The specific gravity of the lung in these forms of pneumonic 
exudation is occasionally as high as 1.050. The exudation of the 
liquor sanguinis into the pulmonary substance in the typhous 
states is not infrequently seen in a consistent and gelatinous-like 
form. Such exudations are generally confined to lobular masses 
of the lung, and a section through such masses presents a dirty 
grumous aspect, with hypostatic congestion in the posterior parts 
of the lower lobes. In connection with such exudations, the 
bronchial glands are very commonly enlarged. 

The exudation in the lungs during the typhoid state is not, 
however, of a constant form. It is sometimes diffused generally 



196 TYPHOID. 

throughout the lung, often as a miliary deposit in the ultimate 
air-vesicles ; at other times, a tolerably well-defined mass of dark 
brown exudation is found, varying in extent from the implication 
of a few lobules to that of a whole lobe, or even a still greater 
part of the lung. Exudations of the former type present, on sec- 
tions of the lung being made, a granular appearance of a dirty 
gray color; and sometimes these little masses soften into a pus- 
like fluid. Such exudations are for the most part found to be 
composed of the retained, compressed, irregular, and otherwise 
altered epithelial secretion of the air cells and air-passages. This 
accumulation appears to result chiefly from the inactive and de- 
pressed state of the pulmonary function associated with the 
typhoid condition. 

The average specific gravity of this form of the solid typhoid 
lung is about 1.042 to 1.043. 

Friability. — The general softening and friability of the texture 
of the lung in the typhoid state is always associated with an en- 
gorged condition of the pulmonay tissue. This engorgement 
consists partly of blood, and partly of exuded bloody serum, the 
result of the tendency which the blood in such cases has to part 
with its coloring constituents and watery elements. The friable 
condition of the parenchyma is most marked in those non-crepi- 
tant parts which no longer contain air. The texture generally is 
softened, without any defind condensation, but some parts are 
more friable than others. 

Pulmonary collapse. — A condensed state of the pulmonary sub- 
stance approaching to carnification is occasionally observable in 
typhoid cases. This state appears to consist in an absence of air 
with lobular collapse. The bronchial membrane is often in these 
instances found intensely congested, and coated with a glairy 
and extremely viscid exudation which blocks up all the finer 
tubes. 

Sloughs. — Sloughs of the pulmonary texture are not uncom- 
mon; they are sometimes symmetrical, as in cases of old stand- 
ing, involving and showing themselves on the pleural surfaces, 
and penetrating to considerable depths in the pulmonary sub- 
stance. A line of demarcation, presenting a congeries of engorged 
and congested minute bloodvessels, separates the dead from the 
living parts. In cases of acute typhoid, likewise, sloughs of the 



GANGRENE OF THE LUNGS IN TYPHOID. 197 

pulmonary substance are sometimes well marked, and rapidly 
tend to a fatal result. 

Gangrene. — Exudations of the typhoid type are sometimes seen 
in the lungs, associated with purulent exudation in the pleural 
cavity, in cases where Peyer's patches are only in an intumescent 
state, and vascular round their borders. In such cases the pul- 
monary lesion has been evidently the one which led to the fatal 
result, and the lung often undergoes rapid changes from exten- 
sive exudations to almost complete gangrenous conditions. The 
broken down gangrenous matter is mixed with elements of a 
purulent character. 

In a well-marked case of typhoid, subsequent to a dysenteric 
process, and prolonged over a period of more than three months, 
the greater part of both lungs was found to have passed into the 
condition of complete gangrene. This state was associated with 
other lesions of the abdominal viscera characteristic of the typhoid 
condition. In the left lung, consolidation of the upper lobe 
existed throughout, with partial red hepatization. A gangrenous 
condition of an extensive portion of the lung was obvious through 
the pleural covering, and a cavity of considerable dimensions was 
found filled with a dirty fluid, and the fetid debris of the pulmo- 
nary substance. 

Bronchial membrane. — In severe and long-continued cases of 
typhoid, the bronchial membrane is generally highly vascular ; 
much thickened, and softened. 

Heart. — In cases of typhoid the heart is often flabby and soft, 
and its texture friable; but I have never observed the same 
extent of degeneration and of the "fishy" condition, such as we 
find to be produced in extreme cases of typhus. 

The various affections of the solitary and aggregate glands just 
noticed may be summed up as follows : — 

Solitary glands of ileum, and Peyer's patches. — The various states 
of these parts are — 1, infarction and intumescence, with different 
kinds of deposit; 2, softening and ejection, in various ways, of 
these deposits; 3, ulceration, sometimes leading rapidly to intense 
and complete sphacelus of whole patches of glands ; in other 
instances, being attended with excessive fungating growths on 
the borders of the ulcers, reaching, in extreme cases, to a quarter 
of an inch in thickness ; 4, several states and conditions of atrophy 



198 TYPHOID. 

of both the solitary and aggregated glands, leading to collapse 
and final degeneration of the vesicles, with the deposit of mela- 
notic matter as a characteristic of pre-existent and long-continued 
vascular action ; 5, cicatrices of healed ulcers which are occa- 
sionally, but not very commonly, to be found. 

The minute characters of these various deposits are : 1st, in 
the states of infarction and milky intumescence (well observable 
in cholera cases), variously metamorphosed epithelial elements; 
2d, in the typhoid cases (chiefly), minute granular, fibrinous, and 
imperfectly developed nuclear and minute cellular elements. 

Solitary glands of colon. — Though not directly connected with 
typhoid, it may be not uninteresting to describe here a peculiar 
state of the minute glands of the colon. Small abscesses, it will 
be found, sometimes exist, associated with an advanced dysenteric 
process. The exudation having been first deposited in a solitary 
gland vesicle, the gland cavity became gradually distended ; ulti- 
mately the exudation commenced to soften, and, combined with 
the condition of an increased vascularity in its vicinity, an abscess 
was formed, which opened upon the mucous surface through the 
little canal which leads from the surface to the gland. Such little 
abscesses freely distributed on the mucous membrane often give 
a peculiar character to the dysenteric process. They are some- 
times arranged in symmetrical double rows through the colon, 
and are often associated with true dysenteric exudations ; but we 
have met some cases in which the condition existed isolated, and 
I have ventured to term it "Follicular Colitis" or "Pustular 
Dysentery." A similar dysenteric process has not infrequently 
been found established in connection with the tuberculous dyscrasis. 
In such cases, the exudation has for the most part assumed the 
diphtheritic form in the first instance, the mucous membrane 
underneath being red, swollen, and deeply injected. The solitary 
glands became gradually infiltrated with exudation, and ulti- 
mately began to soften and to ulcerate, till numerous small 
circular ulcers were established throughout the mucous surface. 

Peyer^s patches. — It may be said that in no case of true typhoid 
fever, taking indiscriminately all those submitted to careful post- 
mortem examination, has a perfectly healthy state of the minute 
glandular apparatus of the intestines been found. Peyer's patches 
participate largely in the various morbid changes observed. 

In the choleraic typhoid state, the patches of Peyer are generally 



TUMID STATE OF PEYEK's PATCHES. 199 

tumid, and often loaded to excess with a remarkable whitish 
creamy exudation, similar to that which is found to fill the soli- 
tary follicles in the same cases. The process of elimination 
attempted when the patient survives for some days, appears to be 
the same in both these structures. 

In the typhoid condition, Peyer's patches present states varying 
from marked and prominent intumescence of their follicles to 
destructive ulceration of the whole glands. They are often filled 
with a tawny colored exudation. In some cases ulceration, intu- 
mescence, and atrophy are present in one and the same case, 
clearly showing that the elimination of the typhoid deposit is 
effected in several different ways. The total destruction to com- 
plete sphacelus of the entire gland patch has been found to occur 
as early as about the twelfth day of the disease. The process of 
change is, however, in the majority of cases, very chronic. 

These glands were all but invariably found affected to a greater 
or less extent in the sequel of the graver fevers which prevailed 
both in the Crimea and at Scutari. 

In a case of sudden death from the rupture of aneurism into 
the pericardium, an opportunity was afforded of observing the 
condition of Peyer's patches about two months after an attack of 
fever. 

The tumid condition of Peyer's patches was peculiar in this 
respect, that towards the ends of some of the patches the vesicles 
of the glands were excessively distended with milky contents, 
and little masses of the vesicles were similarly distended in the 
midst of the patch, the rest of the patch being completely bare 
and dotted over with melanotic deposit. The solitary glands of 
the colon were in a similar state of turgidity and intumescence. 
In this case there appeared good reason to believe that the elimi- 
nation of the typhoid deposit in the glands bad taken place with- 
out any ulcerative action, but at the expense, through atrophy, of 
the gland substance. 

In some cases in which the dysenteric process was established 
subsequent to a typhoid attack, and ultimately proved fatal, it 
was interesting to observe the condition of the glands of the in- 
testine as regards the progress of development or the elimination 
of the deposit. For the most part, Peyer's patches were found 
bare and atrophic, without any evidence of an ulcerative process 
having taken place. Towards the enecum, however, the remains 



200 TYPHOID. 

of ulceration were sometimes well marked, gland patches being 
found with high pulpy edges and dark gray central sloughs, the 
metamorphoses being generally confined to isolated portions of 
a patch, the remainder of which appeared either natural and full 
of secretion, or bare, atrophic, and worn away. In the vicinity 
of these patches, great congestion existed, especially around those 
which were the seat of ulceration. Where the sloughs had sepa- 
rated, a clear mucous looking base covered the muscular layer 
beneath. 

An intense state of intumescence prevailed in many cases of 
typhoid, without having gone on to ulceration, or even to soften- 
ing. 

The specific gravity of Peyer's patches varies greatly, accord- 
ing to the nature and stage of the exudation. The highest specific 
weight observed by us was 1.044 ; the lowest, 1.032. 

Even in the same case, considerable latitude is to be observed 
in the range of the specific weights of the glands ; thus, in one 
case, three patches were respectively 1.032, 1.036, and 1.039. 

These glands present very varied chronic states. 1st. An 
atrophic reticulated condition, in which the gland substance is 
not only empty, but devoid of all glandular element. This con- 
dition may arise from the natural wearing away of the gland, or 
from efforts for the elimination of deposits or exudations ; the 
process of elimination taking place, as we have reason to think it 
did, in some cases without ulceration, but being accompanied with 
the destruction of the gland, vesicles. This process was observed 
to leave a reticulated appearance in the gland, arising from the 
natural interlacement of the interglandular texture around the 
empty cavities being rendered more prominent. 2d. Remains of 
previous ulceration of the aggregated glands are sometimes ob- 
vious with various degrees of distinctness. Congested and thickly 
distributed bloodvessels can be seen in the vicinity, or even in 
the gland patch itself, and mark the increased vascular action 
which had accompanied the morbid changes. 3d. The follicular 
spaces are, in other instances, covered over on their mucous sur- 
face with a dark granular matter ; the mucous membrane is in 
some places removed, and the openings of the follicles are bare, 
prominent, and patulous. 4th. In some instances, the reticulated 
appearance described above is the only remnant of the gland 
patch to indicate its former site ; while, in the more obvious ex- 



GLANDULAR ATROPHY OF SMALL INTESTINES. 201 

amples, there is a well marked cicatrix, for the most part limited 
to a circular spot, in the midst of an otherwise comparatively 
healthy gland. This is covered over with a thin clear skin-like 
membrane of pale color, and with a wrinkled contracted border. 
Extensive congestion exists round the margins of the patch in 
these cases. 

Glandular atrophy of small intestines. — A remarkable condition 
of the mucous membrane of the small intestine, very commonly 
found as a result of prolonged morbid states of a complex kind, 
requires some special notice here. 

The general appearance presented by the mucous membrane 
and substance of the gut in the condition referred to, is such as 
at once to attract attention. 

Attenuation of the substance of the intestine is the most 
marked feature which presents itself; the mucous membrane is 
easily broken down, and is very friable. This condition is found 
to consist in an atrophy of the glandular substance of the mucous 
membrane. 

This atrophic state was rendered apparent by thin sections of 
the mucous substance of the intestine made by Valentin's knife, 
and submitted to microscopic examination. 

The regular and usually turgid follicles and tubes which com- 
pose the great body of the mucous tissue are in a condition of 
more or less complete atrophy or degeneration. 

The tubes are irregular in form and size. They do not lie 
close together, but are separated from each other, and as if im- 
bedded in a matrix composed of granular particles. Their bul- 
bous extremities seem to have disappeared, or become encroached 
upon and obliterated by the fine granular fibroid-like material 
which now forms the chief substance of the gut; and the contents 
of the glands are chiefly composed of fine granular or melanotic 
particles. 

In cases of long-continued complex disease, as when one set of 
lesions has succeeded upon another, as, for example, when dysen- 
tery occurred subsequent to typhoid fevers, or vice versa, we have 
frequently found this atrophic condition well marked. The small 
intestine in such cases appeared thin and wasted; the tubes to- 
wards the upper portion of the gut being obviously degenerated. 
They were of very unequal size — some abnormally distended, 
and that at irregular intervals, giving them a varicose appearance; 



202 TYPHOID. 

their contents consisting of granular and molecular matter, with 
clear cells interspersed ; others seemed to contain fatty granules. 
This follicular disease of the intestine seemed, in some instances, 
to be intimately associated with the diphtheritic process. In the 
colon, for example, the ulcerative process has been seen to be 
established beneath the diphtheritic exudation, the ulcers present- 
ing a clear chipped-out like appearance. Microscopic examina- 
tion showed the follicles loaded with secretion; and in parts these 
follicles were obviously highly vascular to the naked eye. This 
increased vascularity was seen to be especially remarkable amongst 
looped vessels round the follicles in the submucous tissue. Mi- 
croscopically the exudation was granular. Large yellow masses 
(like changed blood after extravasation) were inclosed in areolar 
spaces in the submucous tissue. The ileum was thin and wasted 
towards the upper part ; this atrophic change extended into the 
jejunum, where it gradually disappeared. Section showed the 
follicles irregularly filled, the secretion granular and fatty, and 
sometimes cellular, but the appearances were not uniform. Cel- 
lular exudation existed where the follicles were most distended : 
granular, and, in some places, fatty matter where the follicles had 
become irregularly shrunken or wasted. 

Some morbid conditions of other parts have been observed to 
be associated with intestinal atrophy in chronic and advanced 
cases of typhoid disease. 

In the cases in which this atrophic wasting or degeneration of 
the mucous membrane of the intestine occurs, it may be con- 
stantly also observed that the mucous membrane of the mouth 
is thin, transparent, pale, and bloodless : the mucous glands of 
the lips and cheeks become especially obvious, shining through 
the worn buccal membrane, and they appear small and firm, con- 
taining much dense granular matter. 

Mesenteric glands. — These glands participate largely in all the 
pathological conditions induced by the typhoid lesion in the small 
intestines. The first condition noticeable is that of sanguineous 
engorgements; the individual glands are found enlarged, promi- 
nent through the mesentery, of a deep purplish color, and on 
section exude venous blood in large quantities. At a farther 
stage we observe the glands filled with a deposit very similar to 
that which occurs in the solitary and aggregate follicles. At this 
period the congestion is much diminished, the gland texture 



SPLEEN. — KIDNEYS. — LIVER. 203 

seeming to be infarcted with an abundant exudation of the ty- 
phoid matter, in various states of consistence, sometimes creamy, 
sometimes semi-solid, occasionally of a dirty whitish color, and 
often of a dark brown. The individual glands sometimes reach 
a very large size when thus charged with deposit — I have seen 
them as large as a pigeon's egg. In the most advanced condition 
of the deposit into the mesenteric glands, I have found it degen- 
erated into a dense calcareous mass of irregular form. This is a 
chronic change. 

Spleen. — Considerable enlargement of the spleen with a varia- 
ble amount of deposit in its substance or beneath its capsule, has 
been observed. In some instances the weight of the organ has 
reached fourteen ounces. The specific gravity of its substance 
was sometimes as high as 1.059. Beneath the capsule of the 
organ there was often an extensive deposit of yellowish soft mat- 
ter. In other instances, although the spleen did not exceed from 
five to six ounces in weight, yet its parenchyma was irregularly 
condensed with exudation, and in these cases the amount of the 
change was best indicated by the specific and not the absolute 
weight of the organ ; thus, with a weight not exceeding six ounces 
the specific gravity of the spleen in several parts varied from 
1.052 to 1.059. 

Kidneys. — The kidneys often exhibit very marked changes. 
We have found them increased by more than two volumes. In 
one instance they weighed respectively, the right 10 ounces, the 
left 8J ounces. In another case the enlargement was still more 
excessive; the right was found to weigh 10J ounces, and the left 
13 ounces. The organs were soft, mottled on the surface, of a 
mixed red and yellowish hue, the capsule easily detached, and 
the cortical portion, coarse granular, and comparatively greatly 
enlarged. The enlargement was generally irregular, usually, 
however, most considerable in the cortical substance, which was 
tumid and coarsely granular, often with excessive congestion of 
the pyramids. 

On microscopic examination the tubuli uriniferi have been found 
loaded with epithelial debris. 

Liver. — Changes in the liver are found to occur pretty often, 
but with rather variable characters. Thus it has been found soft 
and flabby, with marks of fatty degeneration, while both the 
absolute and specific weights were reduced. Iu one instance the 



204 TYPHOID. 

weight of the organ was only 43 ounces, and its specific gravity, 
1.020. In the same case the spleen weighed 14 ounces, and had 
a specific gravity of 1.048. 

We cannot take leave of the pathological anatomy of typhoid 
fever, without some mention of the singular affection known as 
" Cholera Typhoid." 

In certain epidemics of cholera, it will be found that, in a large 
proportion of the cases in which cholera does not prove directly 
fatal of itself by the violence of the disease in its first stages, a 
transition is observed within a shorter or longer period after the 
subsidence of the proper choleraic symptoms, when the patient 
passes into a low febrile state, which not infrequently proves fatal. 
This state constitutes the so-called " Cholera Typhoid." 

It is not necessary to dwell in detail on the various symptoms 
presented by the patient under these circumstances. The appear- 
ances are those of a case of well-marked typhoid, and the fades 
typhosa is so characteristic, that by an ordinary or incautious ob- 
server the case would certainly be set down as one of typhoid or 
typhus fever. The abdominal symptoms of pain and distress, 
with diarrhoea more or less marked, and occasionally ileo-caecal 
gurgling, complete the resemblance to typhoid. On post-mortem 
examination in fatal cases of this kind the following appearance 
will be noticed. 

Stomach. — The condition of the mucous surface of the stomach 
generally varied a good deal. The color was sometimes pinkish, 
indicating great increased vascularity, but this was seldom to the 
same extent as that to which we have found it to reach through- 
out the greater part of the small intestine. We have known the 
stomach to present features of an opposite character, the cardiac 
mucous surface being blackened, and in some parts emphysema- 
tous, and showing evidences of altered extravasations of blood 
under the mucous coat. Many of our examinations were made 
at a pretty early period post-mortem (often within six hours) ; 
consequently the normal histolytic changes were but little ad- 
vanced. This may account for our finding but very rarely the 
state of softening and detachment of the epithelium, and the gene- 
ral glairy gelatiniform softening of the mucous membrane which 
has been noticed by some authors. It may perhaps be as well to 
state here, that we are hardly disposed to attach any special im- 
portance to the conditions of the gastric mucous membrane, as 



205 

observed post-mortem in cases of cholera. Not only are they of 
the most opposite kind, but it may be fairly questioned, in some 
instances at least, how far they are attributable to the action of 
certain medicines or stimulants often very liberally employed till 
within a short period of death. 

Duodenum. — The condition of the glands of this portion of the 
intestine is so subject to variety that we know not what exact 
value to give to the appearances which they presented in some 
cases of cholera brought under our notice. It may be well to 
state, however, that we have seen some very well-marked ex- 
amples of enlargement and infarction of the glands of Brunner 
in cholera cases, in which a similar state prevailed to a greater 
or less extent throughout the remaining portion of the alimentary 
tract. Where these glands are most thickly set in the mucous 
membrane, viz., in the first inch and a half or two inches of the 
duodenum, the enlarged condition was most particularly obvious 
and remarkable. 

Small intestines. — Throughout the jejunum and ileum two dis- 
tinct anatomico-pathological lesions deserve notice. The first 
has reference to the vascular distribution in these organs ; the 
second to certain remarkable states of their minute glandular 
apparatus. Under the first head we have to notice the very 
common, and in the cases of true Asiatic cholera, the almost 
constant occurrence of a uniform rose- pink coloration engaging 
the whole tract, but varying a good deal in intensity in different 
cases, as well as in different parts in the same case. It will be 
necessary here to bring to mind again the similar condition of 
vascularity found to prevail on the peritoneal surface in these 
cases, and which, as we have said, by its bright pink color, 
offered such a contrast to the deep bluish red congestion of 
other parts of the intestine and also of the mesentery. This 
pink vascularity, so uniformly distributed on any given portion 
of the mucous surface, we cannot but consider as an evidence of 
a very active hyperaemic condition. How far this increased 
vascular action may be separated from a true inflammatory pro- 
cess we know not ; but it seems to bear some very close relation 
to the production of one at least of the most marked phenomena 
of the disease, namely, the serous evacuations. It is to be ob- 
served, that the vascularity in question was not transient, nor 



206 TYPHOID. 

did it admit of being removed by any amount of washing of the 
mucous surface. 

Within this uniform pink vascularity, there occasionally co- 
existed more or less well-defined isolated patches of vascular 
injection, presenting distinct ramifications, and either surround- 
ing certain groups of the glands or confined to portions of the 
valvulse conniventes; and in this respect resembling a good deal 
the abnormal conditions of vascular distribution often noticed in 
connection with diarrhoea. 

Deposit in the solitary and aggregate glands. — The condition of 
these structures deserves attention. In a very large number of 
cases, so often, indeed, that we are almost warranted in consider- 
ing it as a constant character, I have observed a peculiar promi- 
nence and enlargement of the solitary glands, more especially 
throughout the small intestine, but to some extent in the large 
intestine also. In the best marked cases, the pale rose-pink 
surface of the whole tract of the jejunum and ileum presented 
the appearance of being thickly powdered over with sago grains 
or other similar minute white particles. The number of these 
little bodies increased very obviously as the termination of the 
ileum was approached. 

This condition was sometimes, but in a much less marked 
degree, continued throughout the large intestine. There is 
nothing new in this observation, though I believe it is one to 
which sufficient attention has not been generally devoted. This 
condition of the glands has been well figured and described by 
my eminent friend Professor Grluge ; and, since first noticed, this 
state of the minute glandular apparatus of the intestine has been 
often verified in cholera epidemics ; it very constantly occurred 
during the prevalence of epidemics of cholera at Oran, in the 
Algerian campaigns of the French army ; and was likewise often 
noticed during the Crimean campaigns. 

As an important limitation to any pathognomonic significance 
which it might be attempted to assign to this condition, it may 
be worthy of note that there has been observed during the pre- 
valence of cholera epidemics the almost constant presence of 
this condition of the minute glands of the alimentary tract in 
all fatal cases occurring at such a time, though in many of them 
cholera was not the cause of death, nor was there reason to 
believe that it had existed within any recent period. To some 



207 

extent ray own observations will confirm this statement. In 
reference, therefore, to its interpretation in cholera cases, we 
might, perhaps, be justified in concluding, that it constitutes one, 
but one only, of certain pathological conditions, the concurrence 
of which has some intermediate relation to the production of the 
choleraic phenomena ; that, in fact, during the prevalence of the 
epidemic constitution of cholera, many present this affection of 
the intestinal glands, each individual case being then in the pre- 
dicament, that, if the other necessary concurrent causes are 
brought into operation, the disease shall be developed in the 
system ; but that failing the active operation of these other causes, 
be they what they may, the cholera state is not produced. How 
far considerations arising out of this view of the subject may be 
capable of explaining many anomalous conditions, and, as they 
are termed, abortive cases of the disease, often found to prevail 
during cholera epidemics, we shall not discuss at present. 

Aggregate glands. — The condition of the aggregate glands obser- 
vable in cholera is very similar to that of the solitary; the same 
filling and general intumescence of them exist in many instances. 
Most usually, these minute structures exhibit a milky color, and 
granular prominence, and in this respect contrast in a marked 
degree with the state presented by them when engaged in the 
typhoid process. 

Throughout Peyer's patches much variety is observable in 
the amount as well as in the position of this accumulated cream- 
like exudation or deposit. In some of the patches it occupies 
but a small part, being confined to one or other of the extremi- 
ties, or a central spot of the patch; in others, again, the whole 
patch is engaged. This white viscid exudation consists for the 
most part of clear nucleated minute cells, representing, as it were, 
the epithelial element in an unripe condition. 

Large intestine. — Throughout this organ, in very many cases, a 
condition of its solitary follicles somewhat similar to that above 
noted is often found to prevail ; and, as might be expected, it is 
most especially observable towards the neighborhood of the 
caecum. 

In both the solitary and aggregate glands, but much less dis- 
tinctly in the latter, three periods or stages of the exudation 
may be defined ; first, that in which the glands are visibly promi- 
nent, the mucous surface distinct and unbroken, and the exuda- 



208 TYPHOID. 

tion still in the white cream-like state. In the next condition, 
the evacuation of the contents of the vesicle has taken place, 
whether by rupture from distension, by absorption, or by actual 
ulceration. When the patient survives sufficiently long, these 
changes appear to progress to a still more marked degree; thus, 
in cases of death on the seventh day, we have found some of the 
lowermost of Peyer's patches in a state of softening and ulcera- 
tion, with considerable vascularity enveloping and passing through 
the patch, while vascular rings surrounded others. 

In the glands of the large intestine it is very commonly no- 
ticed, as already stated, that complete evacuation of their contents 
has taken place, so that the recently distended gland cavity pre- 
sents a flaccid state, and its still patent orifice is recognizable as 
a minute dark spot on the mucous surface. This is the only evi- 
dence of any marked participation in any of the choleraic pro- 
cesses that I have noticed in the large intestine. I have not, in 
any case, found oedema of the mucous surfaces in any degree, 
however small ; and we cannot, therefore, admit any such state as 
the cause of the prominence of the solitary or aggregate follicles, 
as has sometimes been supposed to be the case. We may further 
note that we have not observed in the liver, or any other organ, 
any such minute spherical bodies, resembling in size and general 
appearance the turgescent solitary follicles, as Yirchow has in 
some instances described to exist in these situations. 

What precise relation this remarkable glandular exudation, 
and the enteric irritation which must necessarily be connected 
with its subsequent elimination, by either rupture or ulceration 
of the intestinal follicles, may have to the so-called " cholera 
typhoid,'' we are not in a position to determine; but I think that 
my own observations, combined with those of others, as to the 
very general, though not absolutely constant occurrence of this 
lesion in cholera, points to some more than accidental connection. 
Should such be found to be very commonly the case, a considera- 
ble resemblance would thus be manifested between the typhoid 
and the choleraic dyscrasis, at least in one very essential point of 
their pathological anatomy. 

What may be the usual mode of elimination of the creamy 
deposit in the follicular apparatus of the intestines in non-fatal 
cases, we are not in a position to determine. The cases are 
usually fatal when the state of intumescence is at its height. 



209 

When, however, the patients have survived until the third or 
fourth day of the typhoid state, both the follicles and patches of 
Peyer have been still found tumid with the exudation, and they 
have always presented well-marked vascular rings round their 
margins. In the earlier stage, that is, in the proper choleraic 
period, the "sago-grain" appearance exists without any special 
vascularity round the tumid follicles. But the presence of the 
vascular turgescence in the secondary or typhoid stages undoubt- 
edly indicates the approach of an ulcerative and eliminative pro- 
cess in the glands, which at a still further stage will be found 
actually established. I have seen ulcerations as early as the 
fourth day. In some instances, pretty extensive ulcerations of 
the lowermost patches of Peyer have been found, with vascular 
ramifications passing into the ulcerating gland tissue : this has 
been at a somewhat later period. It is by no means improbable 
that the irritation, and the general intense vascularity, with oc- 
casionally actual ulceration of the intestinal glands, has some 
connection with the development of the typhoid characters. 

This remarkable secondary condition is not always presented 
in cholera epidemics ; but when well developed, it exhibits a most 
close resemblance in its general symptoms to the true typhoid 
state. The system generally is low ; the pulse is weak, though 
sometimes full and rapid ; a general dusky hue of the surface is 
to be observed; but no eruption of any kind, so far as I am 
aware, has been noticed. The eyes are suffused, heavy, and dull; 
the tongue is often thickly coated, sometimes creamy, at other 
times covered with sordes, which are also formed on the lips and 
teeth. In fact, after two or three days, the typhoid state becomes 
as fully pronounced in these cases, as it often is, after a much 
longer period, in the true fevers of this type. The cyanosed con- 
dition in some instances does not disappear altogether for a con- 
siderable time — we have seen it well exhibited even after the 
tenth day ; and perhaps it is this alone that gives, even to an ex- 
perienced eye, any ready indication of the true nature of the 
disease under which the patient is laboring. Otherwise, without 
attention to the history of the case, it would be difficult, if not 
impossible, to distinguish it by the consideration of symptoms 
alone, when it is once well established, from genuine typhoid. In 
one remarkable circumstance, however, the two states differ essen- 
tially. In the "cholera typhoid" the characteristic symptoms, 
14 



210 TYPHOID. 

though we have known them to be well marked to a later period, 
usually begin to disappear at about from the seventh to the tenth 
day; and the re-establishment of the patient, in appearance at 
least, takes place with what seems an extraordinary rapidity, con- 
sidering the apparently profound nature of the malady which had 
oppressed his whole powers but a few days previously. It is not 
to be supposed, however, that for a very large number of cases 
of the " cholera typhoid" there is any such favorable issue, for 
death very commonly takes place within the first ten days. Such 
cases generally show no symptoms of amelioration, but steadily 
progress with a decided determination to a fatal issue from the 
ouset. 

The development of this secondary typhoid fever in cholera 
cases deserves special attention in a clinical point of view, as there 
is certainly some reason to believe that, if not dependent on, it is 
unquestionably often connected with, a secondary enteric lesion. 

Treatment of Typhoid Fever. 

In considering the treatment of typhoid, we must ever bear in 
mind, what pathology shows us to be the preponderating tendency 
of the disease, namely, to develop formidable lesions of the in- 
testinal glandular apparatus. 

In no class of cases do we find that attention to diagnosis at 
the very outset of the disease is of such vital moment. Much 
unquestionably may be done or omitted in the very earliest 
periods of a typhoid fever, which will influence its subsequent 
course for good or ill. 

With the general development of the typhous aspect, or fades 
typhosa, which takes place in the first few days after the patient 
is prostrated by a severe fever of this kind, the physician can 
hardly fail, with common attention to the rules we have laid 
down, to infer that the case he has to deal with must turn out 
one either of maculated typhus fever or of the enteric variety, 
now immediately under consideration. 

If the maculae of typhus and the more profound prostration of 
that form of fever are exhibited between the fifth and seventh 
days, as usually is the case, all difficulty of diagnosis is at an end, 
the case is assigned to its proper place, and proper therapeutic 
means are put in requisition accordingly. 



TKEATMENT OF TYPHOID FEVEE. 211 

If a case with the fades typhosa, or typhus aspect, passes the 
sixth or seventh day without the development of maculae, and 
without that amount of prostration we should expect in true ty- 
phus at this period, we must be on our guard, and give the benefit 
of the doubt to the side of enteric or typhoid rather than to typhus 
or maculated fever. 

As it happens not infrequently that the development of the 
rose-colored lenticular spots of typhoid is delayed to some day 
between the eighth and twelfth, it is obvious that a period must 
often intervene in which diagnosis of a perfectly absolute kind 
is unattainable. Under such circumstances our steps must be of 
the most cautious kind, and beyond general measures to support 
the patient's system we are not warranted in using active medi- 
cines of any kind. When the rose-colored spots make their 
appearance, however sparse they be, if at all characteristically 
present, our doubts are at an end. But it is not to be forgotten 
that, under certain circumstances, the eruption of rose-colored 
spots seems either to be wholly absent in typhoid, or so very 
indistinctly developed that it is impossible to rely on them as 
diagnostic marks. It was a characteristic of the typhoid cases 
which occurred in such numbers in the army of the East, during 
the late Crimean war, that the eruption was but very rarely 
developed, and in many instances was not well recognizable at 
any stage of the fever. 

We are now in a position to consider the clinical relations of 
the various pathological states which we have just described some- 
what in detail, but yet in an incomplete manner, due regard being 
had to their practicaHmportance. 

We already, at the outset of our inquiries into the pathology 
and clinical history of typhoid fever, made a practical division of 
the cases of this disease, which we ordinarily meet with in prac- 
tice, into two principal forms, viz : — 

A. Cases of typhoid fever, with contemporaneous deposits in 
the minute glandular apparatus of the intestines. 

B. Cases of typhoid fever, in which the deposit into the minute 
glandular apparatus of the intestines takes place at the close of 
the primary pyrexial period, and after a variable interval of con- 
valescence more or less complete, undergoes a process of matu- 
ration, and then gives rise to a secondary fever. 

In the first form of typhoid fever, or that with contemporaneous 



212 TYPHOID. 

deposit in the minute glands of the intestine, we may expect, as 
already explained, a fatal issue from the violence of the febrile 
impression, from sphacelus of the intestinal walls, embracing the 
patches of Peyer, or from penetrating ulcers perforating the 
serous coat, and producing extensive peritonitis. Lastly, death 
may ensue from hemorrhage, or exhaustive diarrhoea, with gene- 
ral abdominal irritation. 

In the second group of cases, results similar to those just de- 
tailed may occur ; but they present themselves at later intervals. 

Amongst the practical dangers from the ulcerative action set 
up in the intestines, peritonitis is, without doubt, the most formi- 
dable. It may occur without actual perforation of the intestinal 
wall. Thus a typhoid ulcer, eating deeply through the mucous 
and submucous tissues, may not infrequently be noticed, which 
exposes, and ultimately destroys, the muscular textures. When 
the inflammatory process has effected the erosion of all the mu- 
cous tissues, we sometimes find, that from the contiguity of parts 
the inflammatory lesion is propagated to the serous membrane, 
which, in its turn, becomes the seat of violent inflammation. We 
have here an instance of peritonitis developed to a formidable, 
and, it might be, to a fatal extent, without actual penetration of 
the serous membrane itself. When the case dies at this period, 
general agglutination of the abdominal viscera by recently exuded 
lymph will be noticed. When ulceration of the solitary or aggre- 
gate glands exists, the case is liable at any moment to the occur- 
rence of perforation. 

The symptoms which attend perforation are usually of a well- 
marked kind. There is often sudden accession of pain, which is 
very severe, and attended with a peculiar depressing effect. In 
not a few instances the patient is himself made aware of the 
moment at which the perforation of the intestine takes place by 
a sensation "of something having given way" within the cavity 
of the abdomen. There is soon induced a state of more or less 
complete collapse, with an expression of the features, and a 
peculiarity in the general attitude and decubitus of the patient 
which, to an experienced eye, at once disclose the nature of the 
case. No morbid condition, in fact, is attended with a more 
thoroughly characteristic and almost stereotyped physiognomy 
than that which we observe in peritonitis from perforation. The 
features of the face assume a peculiar pinched expression, with 



PERITONEAL PERFORATION. 213 

vertical rugae over the root of the nose, dilatation of the alaa 
nasi, and depression of the corners of the mouth. The breathing 
is quick, and the respirations are short and incomplete; the 
respiratory movements, if closely studied, will be seen to be 
almost exclusively confined to the anterior and lateral parts of 
the chest ; the motions of the diaphragm are reduced to a mini- 
mum; and the alternate heavings of the abdominal walls, so 
regularly noticed in the state of health, are all but suspended. 
The patient usually lies on his back in a constrained attitude, 
the lower limbs being flexed, with the knees drawn up ; while 
on the anterior wall of the abdomen the recti and oblique mus- 
cles are in a state of medium but persistent contraction, with the 
object of bearing off pressure from the parts within. The abdo- 
.men is hot and painful, and even moderate pressure with the 
hand produces intolerable suffering and distress, often with a 
sense of sinking. When the collapse is extreme, the patient lies 
supine, much sunk down in the bed, and the legs are extended 
at full length. 

The pulse is easily affected in these cases, and becomes small, 
weak, thready ; or if it retain any considerable expansion, it is 
of the character known as an oppressed pulse. But the characters 
of the pulse are certainly not constant in peritonitis from perforation. 
At the outset the pulse is occasionally all but extinguished ; as 
reaction takes place it rises in frequency and begins to expand, 
but hardly ever recovers the volume it had previously to the 
occurrence of perforation. The rate is variable ; it may reach 
in extreme cases 130, 140, or 150 per minute, and again it may 
not pass 100 when the lesions are both profound and long-con- 
tinued. Increased action of the abdominal aorta has been occa- 
sionally noticed after, and in some few instances prior to, the 
occurrence of perforation. The action of this vessel is in these 
cases in marked contrast as to force and volume of beat to those 
of the radial artery. The mesenteric, the iliac, and even the 
femoral arteries have been known to participate in this irritative 
action. 

In making post-mortem examinations in cases fatal after per- 
foration, evidences of more or less extensive peritonitis are met 
with. The peritoneum is everywhere in a state of intense vascular 
injection, and here and there in its parietal as well as visceral 
layers coated with lymphy exudation. Straw-colored serum is 



214 TYPHOID. 

found in abundance in the peritoneal cavity, with yellowish 
threads of lymph floating through it. The intestines are in many 
places firmly agglutinated together, and at the part corresponding 
to the perforation, a nodule of intestine will usually be found 
glued more firmly than other parts to a contiguous portion of 
some of the hollow or solid viscera, or to the parietes. It is often 
exceedingly difficult to detect the point at which the intestine has 
been perforated, so minute is the orifice. If the intestine be kept 
under the surface of the fluid invariably effused into the cavity 
of the peritoneum, in these cases the escape of a bubble of gas 
will often be the readiest guide to the site of perforation. On 
the internal aspect the ulcerated patches must be examined in 
succession and with minute care. The close adhesion which 
takes place between the part of the intestine which is the site of 
the perforation, and the nearest solid or hollow viscus, or the 
adjacent wall of the abdomen, is the means employed by nature 
to remedy this otherwise necessarily fatal accident. If apposition 
is maintained for a sufficient length of time, the orifice in the 
intestine becomes completely closed, and a perfect restoration to 
the healthy state may ensue, by the gradual healing of the 
ulcerated surfaces. The irritated state of the intestine, the con- 
stant diarrhoeal discharges, and the unceasing peristaltic action 
thus induced, too often unfortunately interfere with the healing 
process, and disturb the partially formed and still soft adhesions 
which are commencing to establish themselves between the per- 
forated gut and the adjacent structures. Eresh perforation often 
ensues from this cause, with renewal of the peritoneal inflamma- 
tion, under the influence of which the patient usually succumbs. 
The incautious use of purgatives has been known to produce a 
similar effect, promoting peristaltic action prematurely, detaching 
the perforated intestine from its conservative adhesions, and, with 
the effect of a second perforation, giving rise to a second and now 
fatal peritonitis. 

The therapeutic aim which we should hold in view under these 
circumstances, is to control the peristaltic action as much as pos- 
sible : this can be best effected by the free use of opium, and 
withholding all stimulant food or irritating drink. In the general 
management of a case of typhoid, we must hold prominently in 
view from the outset the necessity of sparing the intestinal mu- 
cous membrane as far as possible, and this as well by the scru- 



DANGER OF PURGATIVES. 215 

pulous avoidance of all medicaments calculated to irritate the 
alimentary canal, as by the judicious selection of such articles of 
food as contain most nutriment and least of excrementitious 
matter. If it were possible to find an aliment the whole of 
which would be absorbed in the upper tracts of the stomach, 
duodenum, and jejunum, without leaving any excrementitial 
residuum to pass through the ileum and colon, I believe we 
should be able to deprive typhoid fever of half its dangers. 

It must therefore be a course from which there shall be no de- 
parture, that when we find a case of fever of doubtful character 
and presenting any of the typhus phenomena, we must abstain 
from the use of purgative medicines, and from all aliments of a 
stimulating or irritating quality. The whole class of emetics and 
purgatives is thus at once proscribed. 

Cases of the typhoid type rarely, if ever, present the same 
tendency to sink at an early period as those of the typhus proper 
or maculated fever. Failure of the circulation is not one of the 
dangers we have to anticipate and guard against in typhoid at an 
early stage. Consequently, stimulants, such as wine, brandy, 
spirits, ether, ammonia, and the like, are not called for in the first 
and second week as in typhus, in which it is of such vital moment 
to anticipate the general prostrating effects of the disease, and 
especially the weakness of the heart's action. 

At the same time, we must not forget that the patient has 
before him a long process of disease, which may extend over a 
period of two months, or even more, and which is rarely, if ever, 
brought to a final favorable issue in less than four or five weeks. 
To support the system adequately is therefore equally a part of 
the physician's duty as to avoid unnecessary stimulation. In the 
first week or ten days of a typhoid case, the physician may have 
some reason to believe that the alimentary canal is loaded with 
the remains of undigested food, or fermenting excrementitious 
matters. Under these circumstances, notwithstanding the cautions 
above inculcated as to the avoidance of purgatives, it will be well 
to commence by washing out the bowels with a mild enema, as 
the enema emolliens of the Pharmacopoeia, the ordinary soap and 
water injection, or, better still, some mucilaginous decoction, as 
that of barley, with or without a tablespoonful or two of bland 
oil. The enema may be repeated if necessary; but we must be 
guided a good deal by the nature of the matters evacuated and 



216 TYPHOID. 

the state of the abdomen, as to fulness, &c, and especially by the 
sensations of the patient. 

From our knowledge of the pathological characters of this 
form of fever, attention must be given from the earliest period to 
the state of the abdomen. While it remains unaltered in volume, 
of natural temperature, and unattended by pain or uneasiness to 
the patient on moderate palpation, we may be free from appre- 
hension of immediate danger. The slightest appearance of heat, 
tumidity, or abdominal distress, must, however, be sufficient to 
make us take the alarm, and concert measures for counteracting 
the known tendency to engorgement of the abdominal organs, 
which is so singular a characteristic of this affection. We must 
not wait in these cases for pain on pressure, greatly increased 
heat, ileo-cascal gurgling, and such signs as tympanitic distension 
of the abdomen, with diarrhceal discharges, and perhaps bloody 
or tarry evacuations. When such symptoms are present, it is all 
but certain that lesions of an advanced kind, and of most formidable, 
and vje may even say fatal, significance, are already established, and 
in the majority of such cases it is now too late to apply remedial mea- 
sures with effect. In no class of cases does the common-sense rule, 
u prevention is better than cure," hold with more forcible effect 
than in these now under consideration. The symptoms we have 
just enumerated constitute the usual stereotyped rules of diag- 
nosis in relation to typhoid ; but unfortunately the nature of the 
case is only too obvious (except to utterly and culpably ignorant 
men) by the time that these phenomena attract attention. 

From first to last our closest attention must be given to the 
state of the abdomen in suspected cases of typhoid, and we must 
be prepared to act with promptitude and decision. Fortunately 
no very heroic measures are demanded at our hands, and we have 
not to decide on the use of medicinal agents which constitute an 
anceps remedium, and which, if they do not cure, may possibly 
kill. 

The means we have to adopt in typhoid, under the circum- 
stances in which we suspect actual determination to the intestinal 
surfaces, consist in the use of leeches, fomentations, poultices, 
and occasionally it may be stimulant embrocations, to the surface 
of the abdomen. Pediluvia, sinapisms to the calves of the legs, 
and other derivative agents may be employed ; while leeches to 



TREATMENT OF ABDOMINAL LESIONS. 217 

the anus constitute, in my mind, a remedy well worth trying in 
these cases. 

If the amount and kind of the ingesta be properly regulated 
from the outset, we shall not so often have to contend with the 
profuse, repeated, and uncontrollable diarrhoea so constantly com- 
plained of in typhoid cases. The amount of the evacuations is 
often very great, while their odor is insupportable: they are fluid, 
and often of the character known as pea soup-like, which term 
well conveys an idea of the consistence, color, and general charac- 
ter of the dejecta in many cases of typhoid. 

In anticipation of the abdominal lesions of typhoid, it would, I 
am persuaded, be a good and safe practice to commence the use 
of derivative measures to the abdomen in the early stage, by the 
use of hot fomentations to the abdomen, and the application of 
leeches whenever there is the slightest symptom of abdominal 
tenderness. We have already dwelt on the singular phenome- 
non of localized irritable action of the abdominal aorta. This 
may be almost invariably taken as a sign of threatened mischief 
in the abdominal cavity, if even it so be that intestinal lesion has 
not been set on foot concurrently with the irritative action in the 
aorta, femorals, iliacs, or the mesenteric vessels. 

Pathological anatomy shows us what a remarkable tendency 
there is in this disease to the disturbance of the equilibrium of 
the circulation, and the determination of an inordinate quantity 
of blood to the serous and mucous surfaces of the abdomen. 
Derivative measures, therefore, actively and early used to the 
abdominal parietes seem naturally indicated ; and indeed nothing 
is more grateful to the patient's own feelings, in a good many 
cases, than the application of warmth and moisture to the abdo- 
men. 

On such measures as poultices, fomentations, leeches, or stimu- 
lant embrocations to the abdomen, we must mainly depend for 
the relief of the principal symptoms referable to the abdomen in 
typhoid. 

When diarrhoea is a prominent feature, and the dejecta copious 
and offensive, our first inquiry must be as to the kind and quan- 
tity of the ingesta, past and present, and these we must control 
within the limits already defined. If it seems that an amount of 
aliment has been taken in by the patient greater than his system 
can dispose of, we may allow the eliminative action to proceed 



218 TYPHOID. 

for a short time, with a view to clearing out of the bowels all 
their effete, acescent, and irritating contents. It must not be 
forgotten, however, that in many instances the amount of fluid 
passed per anum is out of all proportion to that taken in by the 
mouth. Attempts must be made, under these circumstances, to 
control the irritable action of the intestines, and opium in its 
various forms may be used for this purpose. Acetate of lead in 
doses of from two to three grains in pill, combined with one-quar- 
ter of a grain or half a grain of opium, may be administered every 
third or fourth hour. Chalk mixture and other astringents, as 
Dover's powder, pulvis kino, &c, may likewise be employed. 

Cleanliness, ventilation, and separation of patients in typhoid 
fever are important rules in the treatment of these cases. The 
immediate removal from the wards of the dejecta of the patient 
is a most necessary step ; and far less danger is to be apprehended 
from the free access of air through open windows and doors, than 
from the miasmata which soon accumulate to a fatal degree of 
intensity in close wards and ill-ventilated private bedchambers. 

When gastric symptoms prevail, leeches over the epigastrium, 
occasionally blisters to the same part, and the internal use of 
hydrocyanic acid in one or two drop doses, with or without the 
combination of morphia, will be found beneficial ; cold drinks in 
very moderate quantities, and fragments of ice slowly dissolved 
in the mouth, will also be useful. 

When symptoms of perforation occur, our main reliance must 
be on opium. This drug may be exhibited in any of the usual 
forms; but the pulvis opii, in one or two grain doses every two 
hours, oftener, or less frequently, according to circumstances, is, 
perhaps, the best guise in which to administer this remedy. 
What quantity of opium will be required in individual cases, it 
is quite impossible to say. Our ordinary experience of opium 
would not justify us in carrying its use to the length which we 
find necessary in typhoid fever with intestinal perforation and 
consequent peritonitis. The powers of the medicine seem, in 
these cases, expended in maintaining the patient's system at par, 
and its soporific qualities are, as it were, suspended for the time. 

When we have evidence of actual peritoneal inflammation as 
the result of perforation, leeches must be extensively applied to 
the abdomen, in relays of twenty at a time, till the abdominal 
pain and distress are alleviated. In these cases calomel and 



INTESTINAL HEMOERHAGES. 219 

opium seem suggested by the ordinary rules of our art, but their 
exhibition in combination is of more than doubtful propriety. 
Mercury exerts its specific influence as a mineral poison in many 
cases, no matter how carefully we endeavor to guard its effects 
by opium. The slightest peristaltic movement will serve to dis- 
place the adhesions which nature with a conservative effort is 
establishing. Our main reliance, then, must be placed on opium 
boldly, but at the same time judiciously, employed. As much as 
105 grains of opium have been administered in a single case; 
but this must be looked on as a very extreme instance. Under 
circumstances of not very unusual violence, two grain doses of 
opium, continued at two or three hour intervals for thirty-six or 
forty-eight hours, must be looked on as a very full and even 
liberal use of this drug. It may be that we shall find that, 
within the first twenty-four hours, what with leeches, fomenta- 
tions, and the application of very light and exceedingly thin 
poultices spread on (or better) between folds of fine gauze, the 
symptoms of peritoneal inflammation have substantially dimin- 
ished ; we may now reduce the doses of opium in quantity and 
frequency, the principal aim being to retain the intestines in such 
a paralytic state as will prevent the possibility of any but the 
most insensible peristaltic action. Constipation ensues as a 
natural and highly favorable result, and with this state we must 
not attempt to interfere. If it be asked at what interval after 
perforation of the intestines we may safely administer a purgative 
by the mouth or anus, I should say at no interval, however long, 
till nature spontaneously brings about the action of the aliment- 
ary canal. The junior practitioner will do well never to lose 
sight of the case we have already detailed, which furnishes such 
a salutary warning, and in which the exhibition of a mild saline 
aperient was followed by the detachment of the intestine from its 
adhesions, fresh perforation of the peritoneal cavity, and death 
from the renev/al of the peritoneal inflammation. 

Hemorrhage from the Intestines. — Hemorrhage from the intestines 
may occasionally occur as the result of the intense congestion of 
the mucous surface which we have seen to be so constantly de- 
veloped in typhoid. More usually, however, it would appear to 
be the consequence of ulcerative erosion of the minute vessels in 
the neighborhood of the affected glands. The black or tarry 
evacuations in the fourth or fifth week are, in all probability, 



220 TYPHOID. 

caused in a similar way, only that the escape of blood takes place 
more slowly, this fluid accumulates in the intestine, and, under 
the action of the intestinal gases, and usually alkaline contents of 
the intestine, becomes of a dark hue and tarry consistence. Ace- 
tate of lead and opium, tannin or gallic acid, and occasionally the 
perchloride of iron, seem the appropriate remedies, and are some- 
times successful, while the mineral acids are decidedly contra- 
indicated in my opinion. Too often, however, hemorrhage or 
tarry evacuations, if in any considerable quantity, only too 
plainly indicate the existence of extensive ulcerative lesions, 
over which we can exercise but temporary control : fresh hemor- 
rhage ensues from extension of the erosive action on the intestinal 
walls, and death takes place often after the dejection of little 
altered blood in considerable quantity. With respect to the 
secondary lesions which occur in the course of typhoid fever, 
our attention must be carefully given to the several great organs, 
with a view of anticipating typhoid invasion of their textures. 
The lungs must be carefully explored by percussion and the 
stethoscope, and appropriate remedies must be early exhibited 
when signs of congestion or consolidation are detected. Under 
this head we may refer the reader to what has been already so 
fully dwelt on in reference to the secondary lesions of typhus 
fever. 

Renal congestion, with partial suppression of urine, excretion 
of albumen, bloody discoloration and diminution of the urea and 
salts, are sufficiently often met with in bad cases of typhoid. Our 
therapeutical efforts must be early directed to relieve the conges- 
tion of the organ, by wet or dry-cupping over the loins, mustard 
poultices and such means. Diuretics must be used with caution, 
though it is certainly a clear indication in this class of fevers to 
promote and maintain the action of all the eliminative organs. 

"Wine and other spirituous stimulants are of but doubtful use 
in typhoid fevers. When, however, it seems that, under the 
combined influence of the typhoid poison, and the depressing 
effects of any of the great secondary lesions we have been con- 
sidering, the case appears likely to sink by failure of the vital 
powers, wine may be administered with a liberal but cautious 
hand. The stronger and drier wines, as port, sherry, and Ma- 
deira, are preferable in these cases to clarets, which are cold and 
subacescent, and may promote irritation of the bowels; brandy 



USE OF QUININE. 221 

may likewise be used. We must be guided by the symptoms 
of each individual case as to the quantity and kind of stimulants 
which will be required, and no general rules seem possible on 
this head. 

As a general medicament, applicable in all stages of typhoid 
fever, no drug seems safer or more appropriate than quinine. Its 
employment is not indispensable, but for the reasons urged on a 
former occasion, a safe medicine, given at regular intervals during 
the course of a disease like fever, promotes confidence, and gives 
the physician an opportunity of enforcing order and punctual 
attention to his directions on other matters. 

In those cases in which there is a partial and deceptive lull in 
the fatal symptoms, the administration of quinine may be con- 
tinued with good purpose by the experienced physician, whose 
knowledge of the pathology of typhoid tells him there is possibly 
yet much mischief in store for his patient. 

Typhoid fever, with an interval of partial convalescence. — Nothing 
but the most thorough knowledge of the pathology and patholo- 
gical anatomy of typhoid fever, as we have endeavored to develop 
it in the foregoing pages, will prepare the practitioner for that 
class of most deceptive cases in which partial convalescence is 
established after the third or fourth week of the fever, but in 
which intestinal lesions silently progress. 

In very many instances, doubtless, typhoid fever will be found 
to progress for six, eight, or ten weeks, with only very indistinct 
remission of the pyrexial state, the patient perhaps dying out 
quite exhausted and emaciated at the end of this period ; or, on 
the other* hand, he may slowly progress to final convalescence 
through insensible stages, towards the end of the second month. 

In the class of cases now to be considered, a primary pyrexial 
period is observable, which is sometimes brought to an apparent 
termination by an attempt at crisis, more or less well marked. 
The duration of this first febrile period is very variable ; it may 
be extended over three or four weeks, and we have known it to 
be of not more than eight, ten, or twelve days' duration. This 
was the case in numerous instances during the late Eussian war. 
The delusive convalescence is sometimes as rapid under these 
circumstances as it is really incomplete, the patient returning to 
his ordinary avocations, and perhaps excesses and indulgences, in 
all the full confidence of completely restored health. The modi- 



222 TYPHOID. 

cal attendant is often as much deceived as the patient, who is 
officially returned as fit for duty, or if in private life, gets prema- 
turely a carte blanche to return to his usual employments and 
pleasures. 

We have seen, from pathological anatomy, how deposit in the 
solitary and aggregate glands, to a very large extent, may remain 
quiescent for a long period. It is presumable, that in many such 
cases, with judicious management, the gradual elimination of the 
deposit might have been brought about without the induction of 
ulcerative action in the intestines. Incautious exposure, prema- 
ture exertion, and the use of food and drink of irritative quality, 
insidiously light up inflammation around the follicles and patches 
of Peyer. This process localized for a time sooner or later reacts 
on the system, and secondary fever of a slow and obscure kind is 
developed, with subsequently pain and distensions in the abdo- 
men, diarrhoea, bloody stools, tympanitis, and it may be perfora- 
tion of the intestines, and fatal peritonitis. 

The practical inferences under these circumstances are, to keep 
the patient under watchful care, to restrict his physical exertions, 
and above all things to regulate his dietetics in such a manner as 
to expose him to the least possible risk of irritative action being 
induced in the still delicate mucous surfaces. 

With cases in private life our task is a comparatively easy one. 
Few patients will be so blind to the interests of their own phy- 
sical health, as not to follow with implicit obedience the medical 
and dietetic rules prescribed by an intelligent physician, more 
especially if a wholesome lesson in the pathology of their case is 
communicated to them, just sufficient, without unnecessarily 
alarming them, to give them some insight into the practical bear- 
ings of the regimen laid down for their guidance. 

Amongst the poorer classes, pressed on all sides and at every 
moment by the urgent necessities of their condition of life, and 
the temptations to which they are exposed, precautions of this 
kind are of little avail, unless we can keep them under our own 
eye in hospital. 

. Yery much the same observations apply to the case of men 
employed in the public service, whether as soldiers or sailors. 
The pathology of typhoid fever furnishes another and most con- 
clusive argument for the necessity of convalescent hospitals on a 
large scale in civil as well as in military life. 



TYPHOID FEVEK; IN THE ARMY OF THE EAST. 223 



CHAPTER VIII. 

(SUPPLEMENTARY.) 

Full and complete records of the pathological anatomy of 
typhoid fever are not readily accessible, and I have therefore 
thought that it may not be without interest and advantage to the 
student and junior practitioner to append to the foregoing chapter 
on typhoid fever an abstract of my Keport on the Pathology of 
the Diseases of the Army of the East during the last Eussian 
campaigns. During the investigations then prosecuted on a very 
extensive scale in the hospitals of the camp before Sebastopol and 
in the large hospitals at Scutari, I had the good fortune to be 
assisted by Professor William Aitken, now of the Army Medical 
School, a gentleman of the most eminent attainments and skill in 
pathology and pathological anatomy. 

TYPHOID FEVER, 

AS OBSERVED IN THE ARMY OF THE EAST. 

Of the fevers prevalent in the Army of the East during the 
period of our investigations, the typhoid was undoubtedly the 
most important, and the most fatal. 

Not only was this form of fever found to be immediately and 
directly fatal in several cases, but even after an apparent conva- 
lescence, formidable secondary lesions were very frequently devel- 
oped as a consequence of it. After a more or less protracted 
course, and often with great suffering to the patient, these lesions 
not infrequently brought about a fatal issue. 

It was from this tendency to the development of secondary 
lesions, and also from their very frequently latent character, that 
this variety of fever derived its chief importance. It was not 
uncommon for the febrile symptoms entirely to disappear, a cer- 



224 

tain amount of convalescence to take place, and the patient in 
many instances to return to duty, while, as the issue showed, a 
diseased action was slowly but steadily progressing in his system ; 
the course of such secondary disease being, perhaps, not unin- 
fluenced by the exposures and irregularities of the soldier's life. 
At a period more or less remote from the primary attack, a fresh 
invasion of symptoms took place, liable to be mistaken for a new 
attack of disease, when due attention was not made to the pre- 
vious history of the case. In many instances, however, no such 
period of intermission was observable, and the patient, with im- 
perfect attempts at convalescence, followed by almost immediate 
relapse, passed from the primary to the secondary or tertiary 
stages of the disease. Such attacks we have known to be ex- 
tended in some instances even over a period of some three or 
four months, before a fatal issue took place. 

It is obvious that when such a form of disease is ascertained 
to prevail, the utmost precautions are necessary, not only during 
the primary attacks, but also during periods of apparent conva- 
lescence. Whether or not medical or other means are capable 
of much influencing the course and issue of these cases, we are 
not quite prepared to say, but there can be little doubt that ex- 
posure, irregularities of diet, and excess in the use of intoxicating 
drink, during such fallacious periods of convalescence, when they 
occurred, largely deprived the patient of his best chances of a 
permanent restoration to health. 

It cannot be said that the typhoid fever was at any time absent 
from the camp. The general tendency of all serious febrile states 
was decidedly more to the assumption of the typhoid type than 
to that of the typhus proper. Thus we have known very fatal 
forms of the typhoid disease with profound intestinal lesion to 
occur as the second attack in the group of so-called Eelapsing 
fevers, already noticed. In other instances, the typhoid has been 
the third, and even the fourth in the group of febrile attacks. 
On no occasion, however, within our experience, has there been 
any extensive or epidemic invasion of the disease. At one or 
two periods (end of October and commencement of November), 
we have known it to present itself in a very severe and rapidly 
fatal form, but happily it ceased to spread before it had engaged 
any large numbers of men. 

Cases of this disease, such as we have seen them, admit of divi- 



AS IT OCCURRED IN THE CRIMEAN CAMPAIGNS. 225 

sion into two broad and practically useful classes : narael y, first, those 
which were immediately fatal ; and second, those in which longer or 
shorter periods elapsed between the first attack and the final issue. 

Of the first class of cases, we have met some well-marked ex 
amples, presenting the most full development of the characteristic 
abdominal lesion. These cases on admission presented the usual 
character of the pyrexial state. The face was flushed, the skin 
hot, and the pulse frequent. The complete " typhous" aspect 
was soon assumed ; sordes formed on the lips and teeth ; the skin 
presented a general dusky aspect, with indistinct mottling of the 
surface. It was also, as in other cases, often closely covered with 
minute hemorrhagic and often scorbutic spots, which appearance 
doubtless served much to mask any characteristic eruption. Be 
it from this, or whatever other cause, we have but very rarely 
been able to determine the presence of a well-marked or cha- 
racteristic eruption in cases subsequently fatal by the abdominal 
lesion. We cannot state that any such eruption was positively 
absent ; but, when present, it was obscure, very difficult of re- 
cognition, and frequently, in consequence, overlooked. On the 
whole, we think we are warranted in saying that the typhoid 
eruption was much less marked and much less characteristic in 
the disease as presented in the Crimea, than we have been accus- 
tomed to find it under other circumstances : and we think it is 
not impossible that this may have been to some extent a differ- 
ential character of the form of the disease which prevailed in the 
Army of the East. 

Much variety was observable in the other clinical characters of 
the disease. With regard to those referable to the abdominal 
organs, very opposite conditions seem to have been presented. 
Thus, in a case fatal within from ten to twelve days, with a most 
profound lesion in the small intestine, proceeding in some points 
to actual perforation, complete sphacelus of several of the patches 
of Peyer, and extensive general peritonitis, it is stated in the 
clinical history furnished to us that during the greater part of 
the patient's illness the bowels were regular, and he complained 
of no pain in the abdomen till a short time before death. Such 
a case, however, is decidedly to be regarded as exceptional ; but 
it well exemplifies the necessity for the utmost care in diagnosis, 
and the most scrupulous precautions in treatment; where such a 
type of disease is suspected to prevail, it is needless to observe 
15 



226 TYPHOID FEVER. 

that drastic purgatives are wholly inadmissible. Gastric symp- 
toms were not uncommon in this fever. In some cases irritability 
of the stomach, with frequent vomiting, was an obstinate and 
troublesome symptom. Diarrhoea, with more or less abdominal 
tension and pain, have been very commonly present. Evacua- 
tions of blood per anum have also occurred in the early stage in 
some cases ; in the later stages of the chronic forms of the dis- 
ease, tarry evacuations have occasionally been present, but these 
have been by no means constant or even general characters. 
When perforation occurred, a new set of symptoms was of course 
developed, of a character which could seldom be mistaken ; and 
they usually preceded the fatal issue by only a short period. 

Thoracic complications occurred pretty often, more especially 
in the chronic forms of this fever, but during the primary fever 
we have not observed pulmonic lesion so commonly or to so 
important an extent, as when it occurred in connection with the 
typhus proper ; in the typhoid, in its early stage, we have not 
known more than two or three cases which proved fatal directly 
by the thoracic complications. 

Symptoms referable to the nervous system have presented 
themselves in the typhoid to a less extent than in cases of 
typhus proper. In very low forms of the disease, while in its 
acute stage, we have known bed-sores to be formed ; these affec- 
tions were more common, however, during the secondary periods; 
considerable, and even sometimes excessive, emaciation was like- 
wise often presented in these latter cases. 

The general character of this disease, with the early prostra- 
tion of the patient's strength and his long continuance in a low 
state, bring it clearly under the great typhous type, the chief 
features of which we have already delineated ; and the general 
observations we before made, as to the therapeutic indications 
furnished by a consideration of its pathology, apply here again. 

The following Table exhibits the chief pathological characters 
of some of the most marked forms of typhoid fever which came 
under observation in the late Crimean War. The cases are 
selected from a much larger body of examples, with a view to 
illustrate the several conditions of the enteric lesions, and also 
the various morbid processes associated with this fever in its 
advanced stages. 



ILLUSTRATIVE CASES. 227 



SUMMARY OF THE HISTORY OF THE CASES AND OF THEIR 
CHIEF POST-MORTEM APPEARANCES. 

TYPHOID FEVER, 

WITH FOLLICULAR INTUMESCENCE AND ENTERIC ULCERS. 

Private John Stockton ; 20th Regt. This patient presented diarrhoea 
at the commencement and throughout the course of his illness. There 
was also some gastric irritation, and vomiting occurred from time to 
time. Pain on pressure and gurgling were observable in the ileo-csscal 
region. There was much nervous irritability, attended, towards the 
close of the case, with violent and almost constant subsultus tendinum. 
Bed-sores became established, and death took place on the fourteenth 
day after admission. This case was reported as " Crimean" fever. The 
chief morbid appearances were confined to the small intestine. 

Ileum. — Enlargement and prominence of the solitary follicles existed 
at the upper part; in the lower, the glands were ulcerated. Yery ex- 
tensive ulceration of Peyer's patches existed throughout. 

Mesenteric glands. — These glands were much enlarged and greatly 
congested. 

Kidneys. — The glands were enlarged by about one volume. No other 
morbid appearances were found. 

Private James Jones, aged 20; 28th Regt.; Regimental No. 4,258. 
This patient was an English laborer of unhealthy aspect. On admission 
the symptoms were pains in the limbs, flushed face, and hot skin. The 
tongue is, however, stated to have been clean, and the bowels regular. 
Much thirst was complained of. The pulse gradually became more 
rapid and feeble; there was great restlessness and delirium, especially 
at night. The bowels continued regular, and it is said that no pain in 
the abdomen was complained of. Three days before his death slight 
mucous diarrhoea supervened. The weakness increased till the tenth 
day after admission, when vomiting set in, and death supervened. 

The disease was returned as common continued fever. The morbid 
appearances were chiefly confined to the abdominal cavity. 

Abdomen. — Extensive peritonitis, with effusion of recent lymph and 
serum, and a general agglutination of all the viscera was found on open- 
ing the cavity. 

Ileum. — The whole of this intestine was most intensely congested, 
and of a deep bluish-black color. On opening it, similar appearances 
presented themselves. The whole of the minute glandular apparatus 
was in a state of extreme and extensive ulceration. Several of the 
patches of Peyer were in the last stage of sphacelus, destruction of the 
intestinal tissues down to -and inclusive of the peritoneum having takeu 
place; in some parts the sloughs dropped out, leaving large oval holes, 
on an attempt being made to hold up the intestine. Perforation had 
occurred at several points. 

Private James Jones; 14th Regiment. This patient had had short 
fever, from which he convalesced imperfectly. A second attack super- 
vened within a short period, and was attended by a fatal issue on the 
eighth or ninth day. 



228 TYPHOID FEVER. 

The chief morbid appearances were confined to the small intestines, 
which were deeply congested, and together with the mesentery presented 
a bluish-red tint. 

Ileum. — This portion of the intestine was most engaged, and chiefly 
in its lower half. Some of the upper patches of Peyer were a little 
prominent, red, and swollen; these characters became gradually deve- 
loped towards the termination of the ileum. In the lower third the 
solitary follicles were immensely enlarged; they were conical, greatly 
elevated above the surface, and some of them as large as the biggest 
peas. They were of a mixed reddish and yellowish color, and presented 
the same appearance on section. They were of considerable consistence, 
and presented no evidence of any tendency to softening. The lower 
sets of Peyer's patches were from one-eighth to one-quarter inch pro- 
minent, of a deep brownish-red color, and their individual glandulae 
were much swollen. 

Colon.. — Some of the follicles of the large intestine were similarly 
filled with deposit, but in no instance were they ulcerated. 

The Mesenteric glands were universally enlarged, some to the size of 
large kidney beans, and deeply congested within. 

Private Cusack, aged 19; 49th Regt. This patient arrived in the 
Crimea only a couple of months previous to the illness which proved 
fatal to him. He was of a strumous aspect, with sandy hair. He got 
a short fever, which lasted about seven days, when he convalesced suffi- 
ciently to be able to leave hospital. He was obliged to seek admission 
again in two or three days, when a continued fever of low adynamic 
type developed itself. No maculae were observable. It was stated that 
he had bloody stools on admission : he had diarrhoea for a couple of 
days in the mid period of the disease, but this symptom was not con- 
stant or troublesome afterwards. On the thirteenth day of his second 
illness he was very low, with sordes on the teeth; the pulse was 140, 
large, but very soft and compressible. The face was highly congested, 
and much bronchitis was found over both lungs posteriorly. Bed sores 
formed soon after, but death did not take place till the twenty-fourth 
day of the disease. 

Sectio cadaveris was made five hours post mortem. Thermometer 
about 80°. 

Abdomen. — Considerable congestion of the abdominal viscera was 
found. The small intestines were contracted, at numerous points, to 
one-fourth of their normal calibre; in parts they assumed the cubical 
or quadrilateral form. 

Ileum. — This intestine was deeply congested on its mucous surface, 
and presented numerous deeply eroded ulcerations, chiefly corresponding 
to Peyer's patches, which were completely eaten away down to the mus- 
cular coat. This state of erosion was most extreme in the last three or 
four patches near the ileo-colic valve ; the muscular coat lay bare, red, 
and dry at the base of these ulcers. The borders were thick and ele- 
vated, but exceedingly irregular and angular. There were several minor 
erosions, corresponding to the site of the solitary follicles. The inter- 
vening mucous membrane was thick, and of a dark bluish-red. 

Colon. — More regular oval-shaped ulcers existed in this intestine, the 



ILLUSTKATIVE CASES. 229 

mucous surface running level to the edge of the ulcer. The lower parts 
of this gut showed some dysenteric change. 

Lungs. — Extensive bronchitic congestion existed; the terminal tubes 
were filled with a viscid glairy fluid. 

Private Josh. Wilton ; 82d Regt. ; Regimental No. 3,438. Arrived 
at Scutari from Cephalonia with a draft of troops on the 30th of Au- 
gust, in a low, prostrate, and nearly comatose condition. The pulse 
was rapid and feeble. There was no eruption of any kind visible. He 
remained in this low typhoid state throughout, and gradually sunk, 
without any well-marked local complication other than oppression of 
the thoracic viscera and the vital functions generally. 

This case was returned as common continued fever. 

Examination was made on the 7 th September. Thermometer 79°. 

The body was soft and flabby, the flesh dry and of a dark red color. 

Cranium. — The cortical portion of the brain appeared somewhat 
softened, and the pia mater was in a highly congested state. 

Thorax. — The lungs were engorged throughout, and more especially 
in the posterior and lateral parts; their substance generally was soft and 
friable ; there was no definite condensation ; the friable condition was 
more remarkable in some places than in others. 

Abdomen. — The mucous membrane of the small intestines in the 
upper part generally appeared in a healthy condition, but towards the 
lower part of the ileum it was remarkably thin and wasted. Through- 
out the lower portion of this intestine the patches of Peyer were in a 
state of active turgescence, partly from exudation into the gland folli- 
cles, and partly from greatly increased vascularity in and around the 
individual patches. The exudation, though soft, had not commenced 
to break up or to ulcerate. 

Colon. — The mucous surface of this intestine was dotted over in a 
very marked manner, with the dark minute orifices leading to the solitary 
vesicular glands. For the most part, these glands were in a state of 
intumescence, and felt hard under the finger. They were filled with an 
exudation consisting chiefly of very fine minute cells and granular matter. 

The Spleen was much enlarged, softened, and friable, exhibiting on 
section a pulpy consistence, and a deep mulberry hue. 

Tlte Kidneys were highly congested and swollen ; this state was espe- 
cially remarkable in the comparative increase of the cortical substance 
and its coarse fibrous appearance. 

Mesenteric glands greatly enlarged throughout. 

Color- Sergt. Joseph McGill, aged 32; 33d Regt.; Regimental No. 
2,263. No history accompanied this case, it was returned as febris C. C. 

Examination on July 12th. Thermometer 80°. 

Petechial spots were visible (post mortem) over the iliac regions, the 
feet, the legs, and the arms; no papular eruption existed; the superficial 
veins appeared to contain decomposing blood. 

Thorax. — The heart was flabby and soft, with fluid blood in its cavi- 
ties and in the large vessels. 

In the Lungs hypostatic congestion existed in the lower lobes. The 
pulmonary substance was softened and friable throughout; an exudation 



230 TYPHOID FEVER. 

of a dirty — half gelatinous, half gruinous — material, was confined to 
lobar masses. 

The Bronchial glands were enlarged, particularly those at the roots 
of the lungs. 

Abdomen. — The intestines throughout were distended with fetid gas, 
developed more especially in the colon. The mucous membrane of the 
small intestine was livid, intensely congested, and coated with mucus. 

Peyer^s patches were extensively infiltrated with a dirty white exuda- 
tion, and were surrounded with zones of excessively congested blood- 
vessels. 

This condition of the glands extended throughout the lower third of 
the ileum ; and in the colon, the solitary glands appeared to be in a 
similar state of intumescence. 

The Mesenteric glands were enlarged throughout, and some of them 
were commencing to soften in the centre. 

On Microscopic examination, the deposit presented the usual appear- 
ances of the imperfectly developed exudation in the typhoid condition, 
large clear irregular cells, with a greater preponderance of granular 
and molecular debris. 

Private Jas Vahez, aged 2 T ; 88th Gren. Com. Regt. ; Regimental 
No. 2,263. This case was returned as febris C. C. Inspection was 
made on July 8th. Thermometer, 78°. 

Thorax. — The lungs on both sides were much enlarged ; the amount 
of blood contained in them was excessive. Posteriorly they were soft- 
ened, and much engorged with a bloody serum, and their texture 
throughout was very friable, with entire absence of air in the posterior 
parts. 

The Heart was flabby, and the blood dark and fluid in its cavities and 
in the large vessels. 

Abdomen: Intestines. — Congestion of a dark livid character existed 
throughout the mucous membrane of the ileum. Peyer's patches and 
the solitary glands were filled with a whitish tawny exudation, which 
raised the patches considerably above the mucous surface. Neither 
softening nor ulceration had commenced, but circles of intense vascu- 
larity surrounded both the patches and the solitary glands. 

Kidneys. — Both of these organs had a tumid appearance ; their tunics 
separated with ease, exposing a granular' and highly congested surface. 
On section, the cortical substance was comparatively increased in bulk, 
its appearance coarse, fibrous, and granular. 

Spleen large, with deposits visible over its surface, of a dark purple 
color. On section, its substance appeared granular but firm, and of a 
dark mulberry hue. 

The Mesenteric glands were enlarged, with surrounding vascularity, 
and in some places were commencing to soften. 

Private Geo. Symes, 19th Regt.; Regimental No. 3,420. In this 
case the only account to be obtained showed the chief characteristic 
features of the typhous state ; but the patient had been only four days 
at Scutari from the Crimea before his death. 

This case was returned as febris C. C. 

Post-mortem examination on July 9th. Thermometer 76°. 



ILLUSTRATIVE CASES. 231 

Thorax. — The pleural cavity on the left side of the chest was filled 
with purulent effusion, so as to compress the lung to about two-thirds 
of its bulk. - 

Both Lungs were gorged posteriorly with dark-colored blood, and the 
pulmonary texture throughout was in a softened and friable condition. 
On the anterior aspect of both lungs, on section, there were deposits of 
exudation marked on the surface of the pleurae by considerable opacity 
of that membrane. Small pus-like exudations were here and there dif- 
fused throughout its substance. 

Abdomen. — The mucous surface throughout the small intestine was in 
a highly congested state, and the patches of Peyer were intumescent 
from exudation, but not ulcerated. 

Sergeant-Major Thos. Madden, aged 28 ; L. T. C. Regit. ; Regi- 
mental No. 990. This patient arrived from the Crimea on the 28th 
October, with fever of two months' date ; no farther account being ob- 
tainable of his condition. Examined the day after his arrival ; his pulse 
was small, weak, and wavering; well expressed maculse were observable 
over the chest, back, and arms. The tongue was dry, leathery, brown, 
and excessively furred. Three days after admission his condition 
seemed to improve, his tongue and mouth becoming naturally moist, and 
some sleep was obtained. On the following day, however, sudden and 
violent purging commenced, with rice-water evacuations, but no cramps, 
coldness, or sinking, and urine was passed in small quantity. The purg- 
ing continued more or less during the two following nights and days, and 
he died on the 4th November, having been seven days in hospital at 
Scutari. This case was returned as " Common Continued Fever." 

The body was much emaciated; the muscles were of a dark red color. 

Thorax. — The lungs were bloodless generally, although congested 
behind. 

Fluid and dark blood was found in the heart and great vessels. 

Abdomen: Intestines. — There was excessive congestion throughout 
the mucous membrane of the ileum. Peyer's patches were highly con- 
gested and turgid with exudation, so also were the solitary glands ; but 
neither ulceration nor softening was yet established. The specific gra- 
vity of one of Peyer's patches was ascertained to be 1.035. 

The contents of this part of the intestine were of a dark tar-like 
aspect. 

The Colon contained evidence of old ulceration from the dysenteric 
process, its substance towards the lower part and in the rectum being 
greatly thickened and condensed. Small punched-out ulcers remained, 
with sharp edges and pale bases, irregularly disposed on the mucous 
surface, near the sigmoid flexure. Yascular patches existed here and 
there throughout the rest of the mucous membrane, more especially ex- 
pressed at the caput caecum, where numerous solitary glands were found 
filled with exudation. The specific gravity of the mucous membrane of 
the rectum was 1.044. 

The Spleen weighed 5| ounces ; its specific gravity was 1.058 ; three 
masses of condensed dark-colored exudation existed along the anterior 
border of this viscus, the exudation consisting of granular matter and 
changed blood. 

The Kidneys were large, tumid, and friable, with comparative increase 



232 TYPHOID FEVEE. 

of the cortical substance. Weight respectively, right 5f, and left 
5^ oz. 

Private Hugh Love, aged 25 ; L. T. C. Regt. ; Regimental No. 
1,301. This patient arrived on the 28th October from the Crimea; it 
was ascertained that he had been in hospital since the 4th of June. The 
febrile condition, with considerable thoracic oppression, was well marked 
on his arrival at Scutari. He died three days subsequently. The case 
was returned as "Febris C. 0." There was considerable emaciation of 
the body. 

Thorax. — The left lung was condensed throughout, and was of a 
bright red color on section, and non-crepitant, except a small portion of 
the apex. The lower and posterior parts of the inferior lobe were in 
a similar condition, and the texture of both was friable. 

The Bronchial mucous membrane was highly vascular ; its secretion 
tenacious, and in some parts purulent. 

The Pulmonary artery contained a coagulum ramifying to its third 
and fourth divisions through both lungs. The bronchial glands were 
much enlarged. 

Abdomen. — The mucous membrane of the small intestine was of a 
moist, velvety, not unhealthy appearance, but with considerable conges- 
tion here and there round Peyer's patches. These were firm and pro- 
minent, but not unnaturally loaded. 

The specific gravity of a full firm patch was ascertained to be 1.040. 
That of the mucous membrane of the ileum, 1.036. The jejunum was 
pale and bloodless; its specific gravity was 1.030. The mucous mem- 
brane of the colon and rectum was universally red, but there was no 
ulceration, except in the rectum near the anus, where there were remains 
of a dysenteric process of old standing. The ulcers appeared to be in 
a contracting healing state. The mucous membrane of the colon had 
a specific gravity of 1.037, that of the rectum 1.038. 

The Mesenteric glands were highly vascular. Their specific gravity 
was 1.031 ; that of a pale bloodless one, 1.033. The parotid gland 
was in a state of suppuration, with excessive congestion amongst the 
interstitial tissue of the lobules ; its specific gravity was 1.040. 

The Spleen was of very large dimensions, weighing 20 ounces. On 
section a softened exudation inclosed in a cavity with condensed walls 
was shown, extending over about two inches of surface. This exuda- 
tion was of a yellow color, and consisted of small cells and granular ele- 
ments, chiefly of broken down exudative material. The rest of the 
substance of this viscus was firm in consistence, and of a mulberry 
aspect, with here and there little deposits of exudation in the crude 
state, similar to more crude portions of the large yellow softened mass. 
The capsule was smooth, opaque, and firm. The specific gravity of the 
organ was 1.046. 

The Liver was of large size; weight 96 ounces, of flabby oedematous 
fatty consistence, with congestion of the hepatic veins, which gave it a 
mottled appearance: its specific gravity was 1.043. 

Kidneys. — The left weighed 9 J ounces, the right 7 ounces; their tunics 
peeled off readily, leaving a mottled surface beneath from the stellate 
patches of venous congestion irregularly distributed over it, the intervals 
being extremely pale. Section showed white fatlike depositions here 



ILLUSTKATIVE CASES. 233 

and there in the cortical substance, which was greatly tumefied. A 
piece much infiltrated with exudation had a specific gravity of 1.034; 
a piece less so was 1.036. 

Microscopically, this exudation was made up of epithelial cells, and 
of a large quantity of dark granular matter, with crystals of phosphates. 
The cells appeared to be the proper secreting cells of the gland altered 
by condensation and granular degeneration. 

Private John Gregory, aged 20; 6th Dragoons Regt. This case was 
admitted on the 6th, and died on the 28th of December. 

It was returned as "Febris C. C." 

Examination on the day of death. Thermometer 58°. 

Cranium. — The arachnoid was opaque, with effusion underneath; the 
lateral ventricles were filled with serum, and the choroid plexuses much 
congested. 

Thorax. — Crude tubercle was deposited in both lungs to a limited 
extent. There was besides much congestion of the pulmonary tissues. 

Abdomen: Intestines. — Irregular congestion of the mucous membrane 
existed. Peyer's glands were congested and intumescent, but there 
were no ulcerations. The entire mucous surface was speckled over with 
small spots of a vivid scarlet color; some of the aggregate patches 
exhibited similar spots. The sigmoid flexure of the colon was much 
congested; there were no ulcerations, but in the upper part of the rec- 
tum there was a large isolated patch of lymphy exudation. 

This case was one in which, probably, the scorbutic and tubercular 
dyscrasies coexisted, the latter called, probably, into operation by the 
influence of the fever. 

Private George Nicholas, aged 21; 1th Regt. ; Regimental No. 3,135. 
Admitted on the 8th of July from the Crimea, and died on the 12th of 
August, having been thirty-four days in hospital. 

This case was returned under the head of "Diarrhoea." 

The examination was made on the 12th of August, the thermometer 
being 70°. 

Cranium. — There was slight congestion of the membranes of the brain. 

Thorax. — The lungs were healthy, but their pleurae exhibited old 
adhesions. 

Abdomen. — The intestinal mucous surface generally was congested, 
and of a dark red color. Peyer's patches were deeply ulcerated, espe- 
cially in the lower part of the ileum. These ulcers had greatly thick- 
ened edges with sloughy centres. The spleen was greatly enlarged, 
hard, but easily broken up. 

The Mesenteric glands were enormously enlarged. 

Geo. Gray, aged 20; 2d Bat. R. B. Regt.; Regimental No. 4,451. 
Admitted to hospital on the 23d of July, and died three days afterwards. 

This case was reported as one of "Common Continued Fever." 

Post-mortem examination, July 24th. Thermometer 83° in dead house. 

Cranium. — Great congestion of the pia mater existed. 

Thorax. — Old adhesions of the pleurae on the right side were found, 
with emphysema of the left lung. 

Abdomen. — Peyer's patches throughout jejunum and ileum were in a 



234 TYPHOID FEVER. 

state of softening and ulceration. In the ileum, the softening and ulcer- 
ations were most extensive; in many of the ulcers, a brown slough in 
the centre and well-marked raised edges were observed. 
The Mesenteric glands were much enlarged. 

Driver James Corry, aged 21; R. H. A. C. Troop. Admitted to 
hospital on the 7th, and died on the 11th of December. 

This case was returned as "Diarrhoea." 

Examination on day of death. Thermometer 56°. 

Thorax. — Hypostatic congestion of both lungs. 

Abdomen. — The small intestines were most prominently the seat of 
disease. At the lower end of the jejunum Peyer's patches were very 
prominent, and surrounded with a well-marked ring of congested ves- 
sels. Throughout the ileum the patches of Peyer were largely ulcerated ; 
these ulcers, in the majority of cases, being nearly an inch in diameter, 
with raised edges and brown central sloughs, and close to the caecum 
the ulcerative action had laid bare the peritoneum. 

The Solitary glands were prominent throughout the great intestine, 
with some circular ulcers near the caecum. 

The Mesenteric glands were much enlarged. 

Farrier John Eaton, aged 32; 1st Dragoons; Regimental No. 1,136- 
This patient was admitted to hospital on the 1st of December, and died 
on the 3d of January, 1856. 

The case was reported as one of "Common Continued Fever." 

Thorax. — On sectio cadaveris there was found hepatization of the 
upper and posterior part of the right lung, the texture of which was 
generally congested and friable. The bronchial tubes were filled with 
bloody frothy mucus. 

Abdomen. — Prominence and congestion of the aggregate and solitary 
glands were observable throughout the small intestine, and at lower 
portions of gut half the glands were ulcerated. 

The Colon and Rectum contained ulcers, and other remains of an old 
dysenteric process. 

The Spleen was large and soft, and of a dark red color, and its sub- 
stance pulpy. Weight 7 J- ounces. 

The Kidneys were of a dark red color, with great congestion of their 
substance generally, and of the membranes of the calyces, pelvis, and 
ureter especially. Weight, right 5^ oz. ; left 6 oz. 

Private William Foot, aged 28; 13th L. Dragoons; Regimental No. 
133. Death and examination on the 1th of December. Thermometer 56°. 

This case was returned as "Dysenteria Chronica." 

Cranium. — Nothing of note. 

Thorax. — Extensive vesicular bronchitis pervaded both lungs, with 
scattered spots of lobular pneumonia principally situated at the base of 
the left. 

Abdomen. — The mucous membrane throughout the upper portion of 
the small intestine was generally pale, with a few isolated patches of 
bright red congestion. In the lower portion prominent ulcers prevailed 
in the site of Peyer's patches, covered with a tawny slough. Towards 
the caecum they increased both in number and size, varying from 1 inch 



ILLUSTRATIVE CASES. 235 

to 1 J inches in diameter. No ulceration was found in the large intes- 
tine; its mucous surface was pale. 

Spleen, soft and dark-colored, with friable tissue. 

Mesenteric glands enlarged. 

Private David Prior, aged 20; l?th Lancers; Regimental No. 1,205. 
Admitted to hospital on the 21st of July, and died three days subse- 
quently. 

Reported as a case of "Common Continued Fever." 

Cranium. — Nothing of note; parts comparatively healthy. 

Thorax. — There was considerable lobular pneumonia of the right 
lung, and also some old pleural adhesions on the left side. 

Abdomen Peyer's patches in some parts of the jejunum, and through- 
out the whole of the ileum, exhibited various stages of softening and 
ulceration. 

The Mesenteric glands were much enlarged. 

Private James Lindsay, aged 12; 93d Regt. ; Regimental No. 3,583. 
Contracted fever in the Crimea about the latter end of August; he was 
admitted to hospital at Scutari on the 1th of October, and died five 
days after; thoracic oppression being the most urgent feature of the 
case. 

The disease was returned as "Pneumonia." 

The body was considerably emaciated. 

Tlie Mucous membrane of the lips presented a livid aspect. Within 
the mouth it was soft and turgid, the submucous glands being obscure, 
of soft consistence, and cellular in contents. 

Thorax. — The lungs were adherent at both sides, collapsed unequally 
and insufficiently, the right remaining about double the volume of the 
left. Towards the lower part of the left lung the texture was cedema- 
tous, with excessive congestion of the bronchial membrane, and frothy 
mucus filling the tubes. The right lung was consolidated throughout, 
and friable. The exudation appeared on section to be very uniformly 
infiltrated throughout its substance, consisting, microscopically, of gra- 
nular and fibrinous elements, with abundance of exudative corpuscles, 
breaking up into molecular matter A thin layer of yellow lymph 
covered the serous surfaces, and glued the lobes together. The specific 
gravity of the condensed and friable lung was 1.042. 

The Heart appeared normal; its specific gravity was 1.042. 

Abdomen. — The mesenteric glands were enlarged, but not softened, 
except those connected with the rectum. Their specific gravity was 
1.040. 

Small Intestines. — In this part of the gut there were several ecchy- 
mosed spots and masses of gelatinous-like exudation, in patches scat- 
tered here and there over the mucous surface. 

Peyer's patches were more or less loaded with exudation, the two 
lowermost being extensively ulcerated. The solitary glands of the 
ileum, also those in the vicinity of the ileo-colic valves, were the seat 
of exudation, and some of them were in a state of slough, the mucous 
membrane throughout being generally thin and wasted. 

The Colon was the seat of numerous small ulcers arranged in regular 
lines throughout the sacculi of the gut. An extensive "deposition of 



236 TYPHOID FEVEK. 

black matter existed throughout the mucous membrane, and was espe- 
cially remarkable round the solitary glands. The ulcers appeared in a 
healing state, the mucous membrane around them being soft and free 
from vascularity. No dysenteric exudation existed. Towards the rec- 
tum there was much thickening of texture with some exudation and 
ulceration, the result of a dysenteric process. 

On microscopic examination, the gelatinous exudation was found to 
be composed of hyaloid elements, inclosing numerous blood disks, while 
the exudation in the glands was, for the most part, made up of granular 
amorphous matter, no cellular elements being visible. 

The specific gravity of the mucous membrane not affected with exu- 
dation, both in the colon and in the small intestine, was 1.038. 

Kidneys. — They were large, turgid, and soft, the cortical portion 
comparatively enlarged, and of a coarse granular appearance. Weight 
respectively, right 6 oz. ; left 5£. Specific gravity 1.040. 

Spleen, weight 5 oz., condensed with irregular masses of exudation, 
of a bloody appearance. Specific gravity 1.052 to 1.059. 

Private Robert Irvine, aged 19; 93d Regt. ; Regimental No. 3,560. 
Admitted under the head of "Febris C. C." 

Death and examination on the 9th of December, 1855. Thermome- 
ter 56°. 

Cranium. — Much congestion of the cranial sinuses was found to exist. 

Thorax. — Extensive vesicular bronchitis of both lungs throughout. 

Abdomen. — The mucous surface of the small intestine was covered 
with patches of bright red congestion ; Peyer's patches were prominent 
in the upper portion of the gut, and extensively ulcerated towards the 
caecum. These ulcers were large, with dark edges, and many of them 
covered in the centre with a tawny slough. A few small ulcers existed 
in the rectum. 

Corporal Fred. Sargent, aged 25 ; 13th Regt. ; Regimental No. 1,746. 
Admitted on the 1st of December, and died on the 10th of same month, 
having been nine days in hospital. 

Reported under the head of "Common Continued Fever." 

Examination on day of death. Thermometer 56°. 

Cranium. — Nothing of note; brain and membranes healthy. 

Thorax. — Scattered spots of lobular pneumonia existed in both lungs. 
The pulmonary tissue generally was affected with vesicular bronchitis. 

Abdomen. — The mucous membrane of the intestines, from the lower 
third of the jejunum down, was highly congested, with marked promi- 
nence of Peyer's patches. Throughout the lower third of the ileum 
these patches were all ulcerated, with great congestion of the mucous 
membrane surrounding them. 

The Mesenteric glands were much enlarged. 
* Spleen much enlarged, soft, and easily broken down. 

Trumpet- Major Thos. Johnston, aged 34; 12th Lancers; Regimental 
No. 1,458. Was admitted to hospital on the 30th November, 1855, 
and died on the 22d of December. 

The case was reported as "Common Continued Fever." 
The body was examined on the day of death, the thermometer being 
52°. 



ILLUSTRATIVE CASES. 237 

Cranium. — There was much congestion of all the sinuses of the cra- 
nium, opacity and thickening of the arachnoid, with considerable effusion 
of serum underneath it; congestion of the vessels of the pia mater, and 
some fluid in the lateral ventricles. 

Thorax. — A few old adhesions existed in the pleurae of the left side. 
The mucous membrane of the bronchial tubes was greatly congested. 

Abdomen. — General livid congestion of the intestinal mucous mem- 
brane generally. Peyer's glands were prominent, but no ulceration was 
found. 

The Mesenteric glands were enlarged. 

Private Luigi Calaptesta, aged 25; L. T. C. Regt. Admitted on 
the 12th, and died on the 27th of December. 

Examination of the body on the same day. Thermometer 58° in shade. 

Cranium. — A cyst-like cavity existed in the anterior lobe of right 
cerebral hemisphere, about an inch cube, and filled with a yellow gela- 
tinous fluid, some dense ligamentous bands running across it. The 
surrounding cerebral structure was healthy, and there was no affection 
of the contiguous bone. The arachnoid was opaque, with effusion un- 
derneath. Pia mater congested; excess of serum in the ventricles, and 
congestion of the choroid plexuses. 

Thorax: Lungs. — Extensive sero-purulent effusion into the cavity of 
the left pleura: left lung bound down by partially organized lymph. 
Patches of lobular pneumonia throughout right lung. 

Abdomen. — General congestion of the intestinal mucous membrane 
existed. Peyer's patches were extremely ulcerated, the ulcers being 
large and circular, with dark-colored bases and raised edges. 

Private Nicholas Flint, aged 28; 13th Light Dragoons; Regimental 
No. 1,758. This case arrived at Scutari from the Crimea on 16th Sep- 
tember. On admission diarrhoea was the most urgent symptom, com- 
bined with great thoracic oppression. The marked features of typhus 
fever, with a papular eruption over the abdomen, chest, and thighs, 
rapidly expressed themselves; and delirium, with extreme prostration, 
preceded death, which took place suddenly five days after admission. 

The case was returned as " Catarrh." Examination on 21st Septem- 
ber. Thermometer 63°. 

The body was not much emaciated ; but the subcutaneous veins were 
very marked throughout their course, from the changed and decomposing 
blood which they contained. 

Cranium. — The brain and its membranes were highly vascular. 
Weight of brain 51 ounces. The specific gravity of the cerebellum 
and pons Varolii was 1.040, of central ganglia 1.035. 

Thorax. — The lungs were cedematous, and did not collapse to the 
usual extent; they were crepitant throughout, but irregularly congested 
through their substance; in some places the congestion amounted to 
actual engorgement, accompanied with softening and great friability of 
the tissues. The bronchial membrane, through its whole course, was 
red and moist from the larynx to the ultimate ramifications, and the 
mucous glands of the larynx and trachea were loaded with exudation. 

The Tonsils were greatly enlarged, their follicles being distended with 
an exudation in all respects similar, in general and microscopic appear- 



238 TYPHOID FEVEE. 

ance, to that in the glands of Peyer, consisting of granular and cellular 
elements of very irregular forms and variable size. Their specific gra- 
vity was 1.047. 

Abdomen. — The mucous membrane of the small intestine exhibited a 
highly livid congestion throughout. 

Peyer'' s patches were the seat of the most extensive morbid processes. 
They were loaded and even distended with exudation, throughout their 
whole extent. Their follicles were prominent with soft exudation, and 
loaded bloodvessels were seen ramifying through the substance of the 
patches. The exudation consisted of very fine granular matter, with 
coarse cells of irregular shape and size. 

The Spleen appeared of the usual volume, but was soft; its section 
showed the parenchyma of a pulpy consistence and dark mulberry hue. 

TJie Kidneys were enlarged, and weighed respectively, the right 4f, 
the left 5 ounces. Their surfaces were congested, and the cortical part 
appeared tumid and coarse. The pyramids were compressed, and had 
a bloodless whitish appearance towards the calyces, while the mutual 
margin of the tubular and cortical portions was highly congested. A 
granular fatty exudation was seen, on microscopic examination, to fill 
the tubes, which were irregularly varicose. The specific gravity of the 
cortical portion was 1.053, of' the pyramidal 1.051. 

The Mesenteric glands were enlarged and softened within their cap- 
sules. Their microscopic elements consisted of granules, cells, and 
softened molecular matter. Their specific gravity was 1.050. 

Private Peter Skinner, aged 28; 71st Regt. ; Regimental Xo. 3,375. 
This patient arrived with a number of invalids from the Crimea on 4th 
July ; died on 7th. 

This case was returned as " Febris C. O." Examination on 7th. 

Considerable emaciation existed, with marked change in the blood of 
the superficial veins. 

Cranium. — The parts were normal. 

Thorax. — The lungs were highly congested posteriorly, and the pul- 
monary substance friable throughout, no limited exudation being appa- 
rent. 

The blood in the heart and great vessels was fluid, and dark in color ; 
and the heart itself was soft and flabby. 

The Bronchial glands were enlarged, and the bronchial mucous mem- 
brane of a red hue, and coated with viscid frothy mucus. 

Abdomen. — General enlargement of the mesenteric glands, with livid 
congestion of the mesentery and intestines. The glands were surrouuded 
with an increased quantity of bloodvessels tending towards them in a 
highly injected state. 

The Small intestines appeared contracted, and of a dark hue. There 
was general vascularity over the mucous surface, and all of Peyer's 
patches were in a state of intumescence with exuded material. In three 
of the patches the exudation had softened, and ulceration was estab- 
lished. 

The Kidneys were congested, and the cortical substance enlarged. 

Col.-Serg. Wm. Warrens, aged 31 ; 77th Regt. ; Regimental No. 
1,806. This patient had arrived some time previously from the Crimea, 
where he was said to have had fever. Death took place suddenly. 



ILLUSTKATIVE CASES. 239 

The case was returned as " Febris C. C." Examination on June 
18th. 

The body was comparatively robust. The course of the superficial 
veins was marked on the skin by the fluid and dark-colored blood which 
they contained, and which had undergone change. 

Cranium. — The arachnoid membrane was much thickened, it was also 
opaque, and there was considerable increase in the subarachnoid fluid, 
both among the convolutions and at the anterior and posterior sub- 
arachnoid spaces. 

The substance of the Brain was firm and healthy. 

Thorax. — The areolar tissue throughout the mediastinal spaces, and 
especially that surrounding the great vessels passing to and from the 
heart, was infiltrated with an abundant sero-purulent exudation. 

Lungs. — The right lung was adherent to the parietes, more especially 
towards the apex. The pulmonic substance was in parts condensed, 
and in parts softened ; the posterior portions were greatly congested. 
A section through the pulmonary substance showed granular exudation 
of a dull gray appearance, which in some parts seemed to be purulent. 
The left lung was healthy in texture, but much compressed upwards and 
inwards, towards the dorsal vertebra? and angles of the ribs. A cavity, 
circumscribed by new formations, extended across from the pericardial 
reflection at the root of the lung to the opposite costal wall of the left 
side, containing a large quantity of purulent fluid. Purulent and 
lymphy exudation coated the pleural surface of the lung. 

Heart. — This organ was healthy, and contained firm decolorized clots 
of fibrin. 

Abdomen. — In the small intestine remains of ulceration were visible 
throughout most of Peyer's patches ; a few of them were surrounded 
with a highly vascular ring of congested bloodvessels. Where ulcera- 
tion had not destroyed the texture of the gland patch, its surface was 
marked with distinct rings of black deposit, giving the appearance of a 
number of black dots, corresponding to the follicular apertures to the 
gland vesicles. A lens of low power rendered these openings visible. 
The mucous membrane of the gut appeared otherwise healthy. 

Kidneys. — The tunics were easily separable from the surfaces of these 
organs, exposing a soft, flabby, granular surface, marked with stellate 
congestion. The kidneys were not increased in size, but relatively the 
cortical substance was much swollen, and had a coarse granular texture, 
with here and there a deposit of yellowish substance in the tubes. 

Samuel Tannahill, aged 26 ; 5th D. Gds. Regt. ; Regimental Xo. 
1,285. This patient arrived from the Crimea in a very weak and ema- 
ciated state on the 20th of September. He continued in a low feverish 
condition for some time after admission, and suffered much from vomit- 
ing of an almost purely bilious fluid. For the most part he lay on his 
face, and appeared not to be sensible to pain on pressing auy part of 
the abdomen. A scorbutic-like eruption was visible on the legs. He 
remained much in the same state, the vomiting being the most trouble- 
some symptom, till the Tth of October, when severe diarrhoea set in, 
with aggravation of the febrile condition, and he gradually sank. Death 
took place on the 12th of October, twenty-two days after his arrival at 
Scutari. 



240 TYPHOID FEYER. 

The case was returned as " Febris C. C." 

Examination on day of death. Thermometer 63°. 

The body was greatly emaciated. Scorbutic marks and blood stains 
appeared on the skin in the course of the superficial veins. 

Thorax. — The lungs were nearly crepitant throughout. The right 
was engorged posteriorly, and friable. The heart was small; the blood, 
fluid and dark, both in its cavity and in the great Yessels. 

Abdomen. — The mesenteric glands were enlarged throughout the 
whole extent of the mesentery ; their specific gravity was 1.043. Intus- 
susceptions existed at three different places throughout the course of the 
small intestines, but no lesion of an inflammatory type was to be seen, 
either on the peritoneum or in the substance of the intestine at these 
parts. These appearances, probably, came on at the moment of death, 
or immediately after it, and they have always been seen in those cases 
in which there has been great pain duriDg life, and ulcerations in the 
bowel have been found post-mortem. 

The Intestinal mucous membrane throughout was thin and wasted, 
congestion with ecchymosis being visible at different parts on its sur- 
face ; its specific gravity was 1.037. The stomach also was similarly 
congested, thin, and worn. 

Peyers patches looked as if abraded, showing ecchymosed spots on 
the site of the gland substance, with melanotic deposit and ulceration. 
The specific gravitv of Pever's patches, when congested and turgid, was 
1.044. 

The Colon throughout was studded with small ulcers, confined chiefly 
to solitary gland spots, while the general substance of the mucous mem- 
brane was thin and worn. Xo evidence of the dysenteric process ex- 
isted. The specific gravity of the mucous membrane of this intestine 
was 1.039. 

On microscopical examination, the mucous membrane of the small 
and large intestines was in a state of atrophy from wasting of the folli- 
cular glands, whose contents appeared granular ; there was also gene- 
ral granular and fibroid degeneration of the mucous tissue. 

The Kidneys weighed respectively, right 5J, and left 5f ounces. 
Venous congestion on the surface. The capsule peeled off easily at 
some points, and there was also congestion of the general parenchyma. 
The cortical part was tumid, but without any definite deposit. 

Private Jos. Cutts, aged 22 ; 38th Regt. ; Regimental Xo. 3,583. 
This case was received into hospital at Scutari on the 26th of Septem- 
ber, 1855 ; having been three weeks in hospital in the Crimea, where 
he is stated to have had diarrhoea. After admission he had occasional 
epistaxis, with much fever and hurried respiration. On admission in- 
creased heat was appreciable over the abdomen, with tympanitic disten- 
sion. About three days after admission pneumonic symptoms were 
manifested, the sputa presenting the " rusty" appearance for one day. 
The thoracic oppression became more severe, and during four or five 
days before death the fecal discharges were of a black and tar-like 
nature. His pulse became tremulous, rapid, and thready ; the abdomen 
continued hot, but the patient was unconscious of pain. He replied to 
questions by short, abrupt answers. His countenance became pale, 
pinched, and anxious, and he died on the 14th of October. 



ILLUSTEATIVE CASES. 241 

Post-mortem examination about six hours after death. Thermo- 
meter 65°. 

There was great emaciation, with rapidly advancing decomposition of 
the body, the blood being greatly changed in the superficial veins ; air 
or gas was already present in the areolar tissue. 

Thorax. — The pericardium contained an increased quantity of bloody 
serum. 

Lungs. — Extravasation of blood had taken place into the pulmonic 
tissue of the right side to a very marked degree. On the left side the 
lung was adherent, and the substance of both was greatly gorged, espe- 
cially on the posterior aspect. They were soft and friable throughout. 
A dark clot of blood was found in the heart ; decomposition of the 
blood had rapidly advanced, and the tunics of the large arteries were 
dyed from its coloring matter. 

Abdomen. — The mucous membrane of the small intestine was thin 
and wasted, the lowermost patches of Peyer being ulcerated to a great 
extent, while the remainder throughout the ileum and jejunum were in 
various states of infiltration and softening, with great injection of the 
bloodvessels round the margins of the patches. The specific gravity of 
three was taken; they were respectively 1.032, 1.036, 1.039. 

The Liver was soft, with marks of degeneration irregularly scattered 
over the greater lobe. The weight was 43 ounces; its specific gravity 
1.020. 

Spleen large; specific gravity 1.048, with extensive subcapsular de- 
posit, of a yellow, soft texture, and granular. 

The Kidneys were in the state of cortical engorgement, and weighed 
respectively, the left 5 \ ounces, the right 5^ ounces. 

Corporal Richard Toogood, aged 28 ; 4th L. Dragoons. Only nine 
months' service ; sent sick from the Crimea, and admitted to hospital 
on 2d Sept., 1855. 

The case was entered as one of "Diarrhoea." 

The day after his admission he voided five or six thin but feculent 
stools, without blood or mucus. There was great general weakness and 
emaciation. By a medical board of the 16th September, he was inva- 
lided and ordered to be sent to England, but on the 21st feverish symp- 
toms were again established with marked severity; frontal headache, 
delirium, and rapid pulse were the most marked features; coma super- 
vened, and death took place on the 24th, three days after this febrile 
accession. 

Examination was made on the 25th. Thermometer 65°. 

The. body was greatly emaciated. 

Thorax. — Extensive pleural adhesion existed at the right side. There 
was much general engorgement of the pulmonary tissue, its substance 
being friable. The lung was crepitant throughout, a small portion 
towards the apex aud anterior edge alone excepted. 

Heart. — Healthy ; blood fluid and dark in the heart and great vessels. 

Abdomen. — The spleen was enlarged, soft, and of mulberry-like hue. 

The Kidneys were congested, and presented great relative enlarge- 
ment of the cortical substance. They weighed respectively, the right. 
4| ounces, and the left 5 ounces. 

Excessive enlargement of the Mesenteric glands, with softening in 
16 



242 TYPHOID FEVER. 

some of them, was observed. An intussusception existed in the small 
gut, without any inflammatory action. 

The general surface of the mucous membrane was highly vascular. 

Peyerh patches throughout were in various stages of morbid action. 
Towards the lower part of the ileum more especially, ulceration had 
advanced in the glands to a considerable extent, leaving in some parts 
a clear reticulated appearance, like what remains after the aphthous 
sloughs of follicles have separated. Towards the upper portion of the 
intestine the patches were gorged with exudation, but had not yet com- 
menced to break up or ulcerate. 

Lance-Corporal Geo. Euston, aged 26; 90th Regt. ; Regimental No. 
2,587. This patient was said to have had dysentery after fever in the 
Crimea; died at Scutari, October 16th; case entered as "Common 
Continued Fever." 

Examination on day of death. Thermometer 68°. 

Thorax. — Pleural adhesions on the right side; the posterior half of 
this lung was consolidated, and the bronchial tubes were filled with fluid 
exudation. In the left lung the ultimate air-cells appeared to be dis- 
tended so as to form lobular nodules, filled with exuded matter, through- 
out the substance of the lung tissue. 

The Pulmonary Artery contained a fibrinous coagulum, extending to 
the finer ramifications of the vessel. 

Abdomen. — The omentum was adherent by extensive old vascular 
connections. The stomach was highly vascular on its peritoneal surface. 
The mesenteric glands throughout were excessively enlarged, and some 
of them softened: their specific gravity was 1.039 to 1.042. 

Small Intestine. — Peyer's patches were universally implicated, and 
had commenced to ulcerate at the lower part of the gut. The specific 
gravity of these patches was ascertained to be 1.038 to 1.042. 

Partial peritonitis had existed, corresponding to one of Peyer's 
patches in the jejunum, where perforation had almost taken place. 

A thin and worn condition of the mucous membrane, both in the 
colon and small intestine, was found associated with a general atrophy 
of the follicular glands. The specific gravity of the thinned portion 
was 1.037. 

Colon. — There existed extensive ulceration, the remains of an old 
dysenteric process, in this intestine. Its mucous surface was sprinkled 
over with a considerable amount of melanotic deposit. 

The Spleen was soft and flabby, weighing 8 ounces. Its specific 
gravity was 1.058. 

The Liver was of large size, was soft and flabby, and weighed 60 J 
ounces. Its specific gravity was 1.054. 

Kidneys The right weighed 5J ounces, the left 5J ounces. There 

was a great enlargement of the cortical substance, and much congestion 
around the pyramids, with venous congestion on the surface, and soften- 
ing and adhesion of the tunics. Their specific gravity was about 1.037. 

Private Joseph He wins, aged 30; 10th Hussars; Regimental No. 
1.168. Admitted to hospital on the 2d of August, and died on the 
24th of the same month. He was reported as a case of "Common 
Continued Fever." 



ILLUSTRATIVE CASES. 243 

The examination was made on the day of death. Thermometer 81°. 

Cranium. — The brain and membranes healthy. 

Thorax. — Heart and lungs healthy. 

The lesions were chiefly intestinal. 

Abdomen. — The mucous membrane of the small intestines, and espe- 
cially the ileum, exhibited numerous scattered points of depressed ulcer- 
ation, about one-sixteenth of an inch in diameter; on the outside of 
these ulcers a deep ring of congestion, of a blackish red color, was 
observable. Towards the caecum these ulcers increased in size and fre- 
quency. Posterior to the caecum there was a large abscess filled with 
fetid grumous pus, which extended from the vermiform process (which 
itself adhered to the caecum) to the middle of the ascending colon, being 
imbedded in the sub-peritoneal tissue. 

Private Moses Ewens, aged 23; 44th Regt. ; Regimental No. 2,929. 
This patient had but recently arrived from the Crimea, where he had 
been long sick. The case was returned as "Diarrhoea." 

Death and examination on the 14th of September. Thermometer 69°. 

There was general yellowness of the skin and viscera, 

Thorax. — The pulmonary tissue was oedematous, but presented the 
usual collapse of the lungs on opening the cavity of the pleurae. There 
was also much congestion towards the posterior part of the lungs, which 
presented here and there blue livid patches over the surface of the pleu- 
rae. Exudation of blood had occurred here and there into the tissue, 
and constituted large so-called apoplectic clots. 

The Heart was soft and flabby. 
. Abdomen. — The peritoneal surface of the ileum was of a dark purple 
color, especially remarkable towards the caecum. Peyer's patches 
throughout were for the most part bare and worn away. In one a small 
circular mark, with a smooth skin-like surface, showed the remains of a 
perfectly healed ulcer. Extensive congestion existed round the margins 
of all the patches, and the mucous membrane generally exhibited on 
section a good deal of follicular wasting. Patches of ecchymoses also 
covered the surface of the stomach, which was thin and worn, and much 
contracted. 

The Colon was thin, its solitary follicles distended with exudation, 
which consisted of fine clear nucleated cellular elements, surrounded 
with great vascularity. 

Kidneys. — The right, increased to nearly twice its volume, weighed 
10 ounces; the left less, but weighed 8? ounces. The enlargement was 
considerable, but irregular in both, the cortical substance being excess- 
ively swollen, with a coarse granular appearance and great congestion 
of the pyramids. 

The Mesenteric glands throughout were enlarged. 

TYPHOID FEVER, 

ASSOCIATED WITH OTHER DISEASED PROCESSES. 

Private Frank Osborne, aged 24; 13th L. Dragoons. Admitted 4th 
of September, and died 27th of same month, having been 23 days in 
hospital. Case reported as "Common Continued Fever." 

The body was examined on the day of death. Thermometer 63°. 



244 TYPHOID FEVER. 

Cranium. — Some serum was found effused under the arachnoid; the 
vessels of the pia mater were greatly congested. The lateral and third 
ventricles were distended with serum. 

Thorax. — Capillary bronchitis prevailed throughout both lungs, with 
spots of lobular pneumonia, and a few miliary tubercles in the apex of 
the left. 

Abdomen. — Ulcerations of Peyer's glands were common throughout 
the gut, involving all the tissues, and extending close to the peritoneum ; 
the ulcers increased in size and number as they approached the caecum. 

In the large intestine, small ulcers with dark red edges were dotted 
through the entire tract of the mucous membrane. 

Private William It evil, aged 19 ; 3d Buffs Regt. ; Regimental No. 
3,017. Admitted on the 10th of September, and died on the 3d of 
October, having been 22 days in hospital ; reported to have " Common 
Continued Fever." 

Examination on the day of death. Thermometer 62°. 

Cranium. — Much serum was effused under the arachnoid ; and the 
vessels of the pia mater were greatly congested. The ventricles were 
also found greatly distended with serum, about 6 ounces. There was 
considerable congestion of the choroid plexus. 

Thorax. — The anterior and superior portions of both lungs were 
affected with vesicular bronchitis, the posterior and inferior parts being 
in a state of hepatization, the exudation extending to the centre of either 
organ. 

Abdomen. — Throughout the upper half of the small intestine, Peyer's 
patches were greatly congested, and of a dark red color ; in the lower 
half, these glands were converted into large ulcers, with thickened edges 
of a brown color, depressed centres, and reddish sloughs at the base, 
the tissues being destroyed in some instances down to the peritoneum. 

Some old dysenteric ulcers existed in the colon. 

Gunner James Leister, aged 22; R. A., 3d Bat., 6th Comp. Ad- 
mitted to hospital 10th of December, and died 29th of December. 
This case was returned as " Dysenteria Chronica." Sectio cadaveris on 
the day of death. 

Thorax. — The lungs showed extensive vascular bronchitis, with gene- 
ral hypostatic congestion. 

Abdomen. — The lower fourth of the ileum exhibited a state of very 
livid congestion, and close to the ilioccecal valve there was one large 
patch of ulcerated glands, involving at least three inches of the gut. 
These ulcers had raised edges, with a brown slough in the centre, and 
were of an oblong shape. 

Throughout the colon and rectum the entire mucous tract was stud- 
ded with numerous ulcers, laying bare in some places the peritoneum. 
The mesenteric glands were much enlarged. 

Driver James Cooke, aged 25 ; R. H. A. Trp. Admitted to hospital 
on the 28th of July, and died three days after admission. The case was 
reported as " Febris Remittens." 

The body was examined 1st of August. Thermometer 81°. 

Cranium. — Parts healthy. 

Thorax. — Parts normal. 



ILLUSTKATIVE CASES. 245 

Abdomen. — In the small intestines the upper portions of the jejunum 
and ileum appeared healthy, but the mucous surface of the rest of the 
ileum was congested, especially in the vicinity of Peyer's patches, which 
were in a state of extreme ulceration, and of a dark red color. The 
ulcers varied from one-quarter to two-thirds of an inch in diameter, had 
greatly thickened edges, and in many places had destroyed the muscular 
coat, and on the peritoneal aspect of the gut yellow lymphy exudation 
was effused. 

Colon. — Ulcers, the remains of an old dysenteric process, were visible 
in the lower part of this intestine. The mesenteric glands were con- 
siderably enlarged. 

Private Edward Booley, aged 20 ; 19th Regt. ; Pegimental No. 
3,303. Admitted on the 28th of August, and died on the 12th of Sep- 
tember, fifteen days after admission ; case reported as " Common Con- 
tinued Fever." 

The body was inspected on the day of death. Thermometer 81°. 

Cranium. — Parts healthy. 

Thorax. — At the posterior part of the upper lobe of the right lung 
the pulmonary tissue was extremely hepatized, numerous spots of lobu- 
lar pneumonia also being here and there scattered through the substance 
of the organ"; much congestion, with frothy serum, pervaded the lung 
generally. 

Abdomen. — Throughout the ileum there were numerous and extensive 
ulcerations of Peyer's glands, very various in dimensions, pale in color, 
and with thickened edges. They were covered with a yellow tenacious 
slough. 

In the Colon large ulcers existed throughout its whole tract; they 
were of old standing, pale, and as if punched out of the mucous mem- 
brane. 

The Mesenteric glands were enlarged, and of a bluish-red color. 

Private James Walton, aged 26; 18th Regt. ; Regimental No. 3,312. 
Was brought to Scutari from the Crimea, convalescent from typhoid 
fever. At that time his stools contained a great deal of blood and 
mucus, were frequent, copious, of a liquid nature and brown color, 
" pea-soup" colored. This condition was partially checked, but return- 
ing with more or less violence at irregular intervals, he at last sunk, 
about four months after his arrival from the camp. The case was re- 
turned as "Febris C. C." 

Sectio cadaveris was made on the 19th of July. Thermometer T4°. 

The body was excessively emaciated, and large bed sores existed over 
both trochanters. 

Cranium. — The brain appeared somewhat shrunken under its cover- 
ings, which were wrinkled over the convolutions, notwithstanding an 
extensive sub-arachnoid effusion of clear serum. The pia mater was in- 
jected to a great extent, and not easily separable from the cerebral sur- 
face. 

Thorax. — The lungs were healthy, but the heart was small and atro- 
phic. 

Abdomen. — The patches of Peyer throughout the small intestine were 
the chief seat of morbid action. The upper sets bare and atrophied, 



246 TYPHOID FEVEK. 

those in the middle part still tumid with exudation, while those lower 
down in the ileum, especially towards the colon, were in various stages 
of ulceration, and surrounded with rings of great vascular injection. 

The Colon throughout was very much contracted. Extensive ulcera- 
tion prevailed at the lower part of the sigmoid 'flexure, combined with 
diphtheritic exudation towards the caput caecum. There was also great 
thinness and wasting of the mucous membrane of the large intestine, with 
intumescence of the solitary glands, surrounded by a highly vascular 
circle of congested vessels. 

The Mesenteric glands throughout were greatly enlarged, with much 
congestion of those in the region of the ileo-colic valve and head of the 
caecum. 

Private James Gillings, aged 24 ; 1st Bat. R. B. Arrived from the 
Crimea on the 2Tth of July ; this patient died nine days after admission 
into hospital. 

This case was returned as " Diarrhoea." 

Examination on day of death. Thermometer 80°. 

The body was much emaciated. 

Thorax. — The blood in the heart and large vessels was fluid and dark. 
The heart was flabby and soft. 

The Lungs were marked throughout with much congestion, more or 
less hypostatic. The pulmonary substance was generally friable. Exu- 
dation of large and dense masses was scattered here and there through- 
out the substance of the right lung, and some of these masses were 
apparent on the pleural surface by a bounding line of irregular shape 
and livid hue, and by opacity of the pleura. 

Microscopically, this exudation consisted of large, irregular, broken- 
down cells and granules, with granular epithelial like secretion. 

Abdomen. — There was much congestion of the omentum and mesen- 
tery, with general enlargement of the mesenteric glands. 

The mucous membrane of the Small intestine was highly injected, espe- 
cially throughout the ileum ; Peyer's patches were ulcerated throughout, 
those of the upper part of the intestine being more in the softening than 
in the ulcerating stage, while in the lower part the process of ulceration 
was completely and extensively established. 

The Large intestine also was the seat of ulceration in its whole extent, 
which seemed to be more or less the result of an old dysenteric state. 

The kidneys were enlarged, and highly vascular ; their cortical sub- 
stance was soft and swollen. 

Private Ered. Pike, aged 22; L. T. C. Regt. ; Regimental No. 2,991. 
Admitted on the 11th of December and died on the 16th, having been 
only five days in hospital, the most urgent symptoms being dysenteric. 

Examined on day of death. Thermometer, in shade, 39°. 

Cranium. — There was much congestion of the membranes of the 
brain, with effusion into the ventricles. 

Abdomen. — Peyer's patches were prominent throughout with exuda- 
tion, but ulceration was only established in those of the lower half of 
the ileum. In this part all the ulcers were extensive, surrounded with 
greatly congested vessels. They were generally large, circular, and 
shallow ; of a brown color, with elevated margins. They were most 
numerous close to the colon. 



ILLUSTKATIVE CASES. 247 

The entire tract of the Mucous membrane of the large intestine was 
covered thickly with large deeply excavated ulcers, of a greenish-black 
hue, and with a red centre. The mucous membrane generally appeared 
to peel off without any difficulty. 

In the Rectum extensive large black ulcers were found ; but little trace 
of the mucous membrane was left. The mesenteric glands were much 
enlarged. 

Sergeant Wm. Jeaffrey, aged 22 ; 7 2d Regt. ; Regimental No. 2,766. 
Admitted on the 2d of December, 1855, and died on the 22d of the 
same month, having been twenty days in hospital. The case was re- 
ported as " Common Continued Fever." 

Post-mortem examination on the day of death. Thermometer 52° 
in shade. 

Cranium. — There was great congestion of the vessels of the pia 
mater, of the sinuses, and of the choroid plexuses. The lateral ventri- 
cles were distended with serum. 

Thorax. — A few old adhesions of the pleurse existed on the left side. 
The posterior part of the right lung was hepatized, and the left was 
affected extensively with vesicular bronchitis, the tubes being filled with 
frothy serum. 

The Heart was large, pale, and flabby. 

Abdomen. — Peyer's patches were in various states of morbid action. 
They were prominent above ; and towards the lower portion of the 
ileum, they were extensively ulcerated, the ulcers being of circular form, 
and of a glossy red hue, with now and then an ash-colored slough at 
bottom. 

The Colon and Rectum were the seat of numerous long fusiform dark- 
colored ulcers. 

Kidneys greatly enlarged; weight of right 10 J ounces, of left 13 
ounces. They were soft, mottled on the surface, of a mixed red and 
yellow hue, the capsule easily detached ; cortical portion coarse, granu- 
lar, and enlarged ; tubular part deeply congested. 

The Spleen was large, soft, and easily broken down. 



248 YELLOW FEVER, 



CHAPTER IX. 

YELLOW FEVEK. 

Order I. — Primary Fevers. Class III. — Remittent Fevers. 

Having concluded in the last chapter the description of the 
Continued Fevers, it would be our duty next in order to enter 
on the consideration of the Intermittent Fevers, which constitute 
the second class of the first great order of Fevers, namely, the 
Primary Fevers, according to the arrangement of the several 
varieties of Fever which we adopted in a former part of this work. 
(See Chap. III. p. 46.) As, however, it is not within the scope or 
limits of this volume to treat of this class of Fevers, we shall 
pass on to the study of one remarkable example of the fevers of 
the third class, or those of Eemittent type. 

Yellow Fever is usually classed with the diseases of Eemittent 
type, and in all essential particulars this is certainly the group 
of febrile affections to which it presents most affinity. As we 
shall subsequently have occasion to notice, however, Yellow Fever 
is in certain epidemics marked by a tendency to divide itself into 
distinct and separate stages, rather than by any characters of 
daily remission of the pyrexial phenomena. Yet in accordance 
with general usage, we shall continue to retain it in the category 
of Remittents until Nosologists define its place. 

GENERAL CHARACTERS OF YELLOW FEVER. 

Dr. Aitken defines this disease as follows: " Topographically, it 
is a disease not proved as yet to be one sui generis, endemic only in 
low districts on the sea coast, but under certain circumstances sporadic 
in other places, never appearing beyond 48° of north latitude, nor 
without a temperature of 72° at least, somehow promoting its propa- 



GENERAL CHARACTERS. 249 

gat ion and production, nor above the elevation of 2,500 feet above the 
level of the sea? 

At what historic period yellow fever became an established 
epidemic, it may perhaps be not possible now to determine. 
Some writers, and amongst them Bancroft, seem to think that 
certain of the fevers described by Hippocrates as being attended 
with black vomiting and yellowness of the skin, were of the 
same nature as the yellow fever of later times. I doubt much 
that the question admits of absolute solution, so meagre are the 
accounts left us in the fragments of the works of the great father 
of medicine. 

Eegarding this formidable epidemic in a general way, with a 
view to the determination of its leading nosological features, it 
presents all the characters of a well-marked fever. 

The nervous system is oppressed, the circulation highly excited, 
while the secretions are diminished in quantity, altered or sup- 
pressed. The temperature is elevated, the skin hot and dry to 
the touch, and the thermometer in the axilla indicates an increase 
above the natural standard frequently to the extent of two, four, 
and sometimes even six degrees Fahrenheit. 

The sensorial functions are but comparatively little affected on 
the whole, and it is common for patients to retain possession of 
their faculties till shortly before death; exceptions, however, 
occur to this rule, and cerebral excitement, with delirium and 
other head symptoms, has been observed in a certain number of 
cases in all epidemics. 

It is often difficult to reduce the disease to any distinct type 
of febrile action. Occasionally the fever will be found to occur 
with such characters that, strictly speaking, it does not correspond 
to any of the regular types of continued, intermittent, or remit- 
tent fever; the phenomena are, undoubtedly, perfectly continuous 
in numerous cases for days together; intervals also occur in 
which the patient is devoid of pyrexial excitement of any kind, 
but these intervals are irregular in their periods of occurrence, 
and not by any means constant, and they are certainly wanting 
in any definite character of periodicity. In my judgment, the 
disease will be best described as a fever composed of distinct 
stages or periods ; the chief characters and the order of occur- 
rence of which, though by no means constant and uniform, 



250 YELLOW FEVER. 

observe much regularity in the majority of the cases in certain 
epidemics. 

The cases of yellow fever resolve themselves naturally into 
certain groups, more or less distinguished from each other by the 
presence or absence of well-marked and characteristic clinical 
features. 

Amongst the groups thus distinguishable from each other the 
following are, perhaps, those best marked and most readily re- 
cognizable in the history of different epidemics : — 

I. The algid form. 
II. The sthenic form. 

III. The hemorrhagic form. 

IV. The purpuric form. 
V. The typhous form. 

The algid form is, generally speaking, that which presents the 
most rapid course, the earliest and greatest amount of prostra- 
tion of the vital powers, and which, likewise, offers in most 
frequent combination the most appalling characters of the epi- 
demic reunited in individual cases. 

In many epidemics the mode of invasion of the disease and 
its suddenly fatal effects have given to it peculiar and distinguish- 
ing features, so as almost to entitle it to be considered a separate 
form of the malady. The patient, while in the enjoyment of his 
usual health, and in the midst of his usual occupations, feels 
suddenly the effects, as it were, of a sudden blow from a heavy 
bar on the back, falls down while walking, and dies within a 
few hours in profound collapse, and after exhibiting more or less 
of the other symptoms of the fever. 

I am not aware of the occurrence during any portion of the 
Lisbon epidemic of 1857 of this class of rapidly fatal cases, ver- 
nacularly known elsewhere as "walking cases;" and though 
rachialgia was a common symptom, I did not observe nor hear 
of its occurrence in that intense form accompanied with sudden 
prostration of the vital powers, and rapidly fatal issue, known 
so constantly in the older epidemics as coup de barre, or stroke 
of the bar, from the suddenness and violence of the attack of 
pain in the back or loins, and the " knock-down" influence of the 
disease upon the patient's strength from the first moment of in- 
vasion. 



COUP DE BAEKE. 251 

Such were the cases described by the Pere Dutertre and the Pere 
Labat, in which patients in apparent health walking in the street 
felt suddenly the coup de barre upon the back or loins, became 
from that instant prostrated by the violence of the disease, and 
died; in numerous instances, within two hours from the first 
seizure. The Jesuit and Dominican fathers describe such cases 
as of frequent occurrence in the epidemics of the West Indies, 
and on the shores of the Mexican Gulf. 

Even within recent times, almost equally violent and rapidly 
fatal cases have been met with in the epidemics of Yera Cruz. 

I shall now proceed to consider the clinical characters of the 
several forms of the fever above enumerated, and chiefly as they 
were presented to my observation in the Lisbon epidemic. I 
propose to describe each form of the disease particularly, and I 
think this plan will be found to present many important advan- 
tages. 

I would here observe, that for myself I can have no doubt 
that a great deal of the discrepancy of statement and conflict of 
opinion in the accounts we possess of the several epidemics of 
yellow fever occurring in various localities, has arisen from the 
different forms which the disease presents being confounded in 
one common description, embracing the phenomena of all. It 
will, I think, be pretty evident that the description of an epi- 
demic; in which the variety I shall describe as the algid form 
predominated, must differ essentially from that of an epidemic 
in which the sthenic, the hemorrhagic, or the purpuric varieties 
were most generally presented. The same holds with respect to 
the typhoid form, which, though not a prevailing type in the 
Lisbon epidemic, must, when presented largely in any visitation 
of yellow fever, give a special character to it, and which is un- 
doubtedly that variety from which the designation of Typhus 
icterodes was applied, though erroneously, as we shall see, to all 
the forms of the disease in common. Again, when a writer of 
such experience and acuteness as Bancroft states that he considers 
the term "causos," or ardent fever, that most applicable to the 
designation of yellow fever, it is obvious that his conceptions of 
the disease must have been formed from witnessing epidemics in 
which the variety we shall define as the " sthenic" was the pre- 
dominant type. No one who had large experience of epidemics, 



252 YELLOW FEVER. 

furnishing in number examples of the " algid" variety, could 
have regarded it as in any way resembling the "causos," or burn- 
ing fever of Hippocrates. 

THE ALGID FORM. 

This form of the disease was presented in a very considerable 
number of the cases, during the Lisbon epidemic of 1857, occur- 
ring perhaps most frequently in persons of the very lowest classes. 
It was observed to occur in the very old as well as in the very 
young, in the lean and haggard, and likewise in those of compa- 
ratively robust and well-nourished frames, and in the middle 
periods of life. It was not limited to either sex. I have seen 
well-marked cases in old men and also in boys, in young girls of 
fifteen to twenty, and in old women of sixty. 

This class of cases presented extreme and, in general, early and 
marked prostration of strength. Taking a case in which the 
algid condition was fully developed, the following appearances 
were observable : — 

The countenance was sunken, the eye dull and filmy, the sur- 
face was cold, and the patient felt cold, wretched, and depressed, 
and cowered under the bedclothes; in extreme cases the teeth 
chattered, and even marked general rigors were sometimes ob- 
servable. The face was of a dirty livid hue ; this appearance 
extended to the trunk, which, as well as the remainder of the 
body, often presented innumerable points of minute venous con- 
gestion ; the extremities, and especially the hands and feet, were 
deeply livid, blue, and cold. It was not uncommon in such cases 
to find the skin thickly covered with purpuric spots and patches 
of various sizes. Sometimes there was an universal semicyanotic 
condition of the surface observable, not very dissimilar to that 
with which we are familiar in the algid period of cholera. In 
extreme cases the lips, the breath, and even the tongue, were cold, 
and in some instances we determined the temperature in the 
axilla at 96° Fahr., indicating a diminution of 2° in the animal 
temperature. The pulse was small, feeble, and quick, but it did 
not present any very constant characters. In extreme cases the 
radial pulse was obliterated, and the cardiac action became ex- 
tremely feeble. 

It is not to be supposed that these features were exhibited only 
at the outset of the attack, or for a short period subsequent to the 



HEMOEKHAGES IN THE ALGID FORM. 253 

invasion of the disease. They were not necessarily immediately 
developed in all the cases subsequently assuming the algid form; 
and in some instances a day or more elapsed after the primary 
attack of headache, rachialgia, gastric anxiety, or any of the other 
symptoms which all or singly marked the commencement of the 
disease, before the algid phenomena were presented. As a gene- 
ral rule, these symptoms were of all but fatal augury, and con- 
tinued little altered, if not aggravated, till the final issue of the 
case in death. Many of these cases might almost be considered 
as purely apyrexial ; for, with the exception of slight elevation 
of temperature in internal parts, and the depression of the nerv- 
ous system, there was nothing whatever to indicate that the 
organism was undergoing a process of febrile action. 

Pains in the calves of the legs appear to be much complained 
of in many cases of yellow fever at the outset, and they are often 
the cause of much suffering in the algid as well as in other forms 
of the disease. 

In a very large proportion of cases of the algid form, the 
hemorrhagic tendency was present to the most marked degree ; 
this was evidenced in the several following particulars : — 

(a) By the early and profuse development of purpuric spots 
and occasionally of purpuric patches of variable size on all 
parts of the surface. These spots were especially well 
developed on the chest and neck in females, and upon the 
lower extremities in both sexes. Bloody furuncles are 
occasionally presented on the skin in certain epidemics. 

(b) By distinct hemorrhages from the nose, from the lips, and 
gums, and from the stomach, in the shape of black vomit; 
likewise from the intestines (1), passed per anum during 
life, or (2), found post mortem throughout a greater or less 
extent, sometimes through the whole tract of the small and 
large intestines. 

(c) Hemorrhage took place from the vagina in females, and 
sometimes to a very large extent. These hemorrhages 
were in no way necessarily connected with the menstrual 
period. 

(d) Bloody streaks and patches were frequently presented in 
the expectoration; in some cases there was reason to be- 
lieve that the blood came from the bronchial or pulmonic 
surface. 



254 YELLOW FEVER. 

In several of these cases the blood crusted in the shape of 
thick reddish black sordes on the tongue, gums, teeth, lips, angles 
of the mouth, and alas of the nose ; the patient's face was marked 
with the blood which continually oozed from the gums, lips, and 
nose; the hands were likewise stained with blood, and the bed 
and bedclothes were not infrequently similarly tinged or smeared 
with black vomit, all which contributed much to give the patient, 
as he lay half gathered up and cowering under the bedclothes, a 
peculiarly horrifying and appalling aspect, which once seen left 
an enduring impression on the observer's mind. 

Indeed in this, as well as in the other forms of the disease as I 
observed them, yellow fever has a special and a highly character- 
istic physiognomy, the salient features of which are readily re- 
cognizable and taken in by the practised eye at a glance, though 
they are very difficult of description; and I believe it to be 
impossible to convey by any language, however forcible, an ade- 
quate idea of them. After a now very extensive experience of 
the worst forms of epidemic disease at home and in foreign coun- 
tries, and at the Seat of War, I must avow that I have seen few 
assemblages of symptoms of a more striking and indeed horrify- 
ing character than those often presented in yellow fever cases, 
nor any in presence of which more impressive feelings are called 
forth in the reflecting mind. 

1 have seen many cases the features of which were of a truly 
appalling character. Not to multiply descriptions, I may cite 
from my note-book the following brief statement of the chief 
symptoms presented by a very well-marked algid case. 

It was that of a young girl, aged sixteen (Case 22, Female 
Wards, Desterro Hospital, Lisbon). She was admitted on the 
10th of December, 1857, at 10 P.M., having been ill since the 
4th. She was described as having exhibited hysteric symptoms 
on admission. When seen at the hour of visit (9 A. M.) on the 
11th, she was still in a profoundly algid state, though all proper 
means had been used to restore reaction. She lay cowering and 
shivering under the bedclothes. She was quite pulseless, the 
hands and feet were cold, and the hands soiled with blood; the 
face was of a livid bluish tint, the eyes darkly congested and 
dull, the alas of the nose, and the lips, and teeth covered with 
bloody sordes; the tongue was moist, slimy, and bloody; there 
was complete absence of yellow coloration of any kind, the sur- 



ABSENCE OF YELLOWNESS OF SKIN*. 255 

face generally was semi-cyanosed, and everywhere thickly covered 
with well-marked purpuric spots. Dark blood oozed from the 
nose and gums, and black vomit supervened, and likewise vaginal 
hemorrhage ; there was retention of urine. She was still hysterical 
at the hour of visit, trembling, fearful, and disposed to cry. She 
retained her faculties of sense, could understand questions and 
made efforts to reply, but could not articulate. There was but 
one end for such a case. She died on the following day ; the 
conjunctiva was slightly yellowish post mortem. 

The above description will serve to convey a brief preliminary 
outline of the most remarkable characteristics of the algid form 
of the yellow fever ; it agrees in all essentials with the descrip- 
tions given by other writers. 

It will be observed that there has been as yet no mention made 
of yellowness of the skin or other structures. In fact, this symp- 
tom was very often wanting throughout in this class of cases, 
many of them dying without having ever exhibited a trace of 
yellowness on any part of the cutaneous surface or even the con- 
junctivas during life; its absence being remarkable in these and 
other situations till after death. For such cases the term yellow 
fever was an obvious misnomer, throughout their entire course. 
Complete and entire absence of yellow discoloration during the 
whole course of the case whilst life remained, and after death, 
was however an extremely rare occurrence. Such cases I have 
undoubtedly seen, and I have verified the observation in every 
stage up to the period of death and post-mortem examination. 
It more commonly happened, however, that a slight tinge of yel- 
lowness was observable in the conjunctivas at variable periods, 
often at only very short intervals of a few hours before death 
took place. In other cases, and this by no means infrequently 
happened, the discoloration did not begin to appear till a varia- 
ble interval after death, and then, commonly presenting itself 
first in the conjunctivas, it became gradually visible, spreading 
from the fairer and whiter parts to the more livid, which latter, 
as will be more fully detailed in treating of the external post- 
mortem appearances, it but seldom gained, at least to the extent 
of giving to them any tinge perceptible through the more strik- 
ing lividity of the inferior and dependent parts and the extre- 
mities. 

The clinical history of the algid form, while offering a certain 



256 YELLOW FEYEE. 

uniformity in its general characters, presented much variety of 
its phenomena in detail. The sinking, coldness of surface, and 
depression of the vital powers, were sometimes, as we have already 
remarked, of early occurrence; but they were undoubtedly to be 
observed equally well marked at so late a period as the seventh, 
eighth, or ninth day of the disease. In some instances of patients 
admitted into hospital on the eighth day from the date of the 
attack of cephalalgia, rachialgia, and other primary symptoms, 
the algid condition was very well exemplified. In this class of 
cases it is, I think, fairly presumable, in the absence of direct 
proof from actual clinical observation, that the algid state cor- 
responded to a period of more or less complete remission of the 
febrile symptoms. The pulse was either altogether absent or 
very feeble, and in some cases it was little, if at all increased in 
frequency, while the hands and feet were quite cold and blue, the 
surface generally livid and cold; and the thermometer in the 
axilla marked in one instance but 97°, in another 96°. In the 
cases here alluded to the pulse was respectively 80 and 108 in 
the minute, and very feeble in both. Losses of blood by hemor- 
rhages from the nose, mouth, stomach, or other parts, might be 
assumed, in some measure at least, to have contributed to, if not 
to have caused, the sunken and depressed condition of the 
majority of these algid cases, in which, as we have already 
stated, the hemorrhagic tendency largely prevailed. Instances, 
however, were not wanting to show that the greatest amount of 
sinking and depression of the vital powers was brought about, in 
some cases at least, independently of the loss of blood; for algid 
cases came under our observation with this peculiar condition 
fully developed on the sixth or seventh day, and in which no 
hemorrhage or black vomit had taken place. I have notes of an 
interesting case of a patient (a mason), attacked on the 11th De- 
cember, 1857, at 7 A. M., and admitted to hospital on the 14th, 
in a low, stupid, and semi-comatose condition, and unable to 
answer questions. When seen by me on the 15th, he was still 
half stupid ; the surface was cold, the skin livid, but not remark- 
ably so, and there was an entire absence of any yellow discolor- 
ation ; the pulse was only 80 in the minute and feeble, and the 
thermometer in the axilla stood at 97°. In this case there had 
been, up to this period, neither black vomit nor any other kind 
of hemorrhage. 



STATE OF THE FACULTIES IN THE ALGID FOEM. 257 

State of the faculties in the algid form. — In this, as in the other 
forms of the disease, the faculties, generally speaking, remained 
clear; the intellect was undisturbed, and the patient was in full 
possession of all his senses almost to the very moment of dissolu- 
tion. It happened, however, occasionally that, as in the case just 
cited, the patient fell into a half stupid state; but it was generally 
possible to rouse him, and get coherent answers from him, though 
he relapsed almost immediately into the state of semi-consciousness. 

In females, hysterical excitement and various nervous pheno- 
mena were not unfrequently exhibited. Wandering and deli- 
rium were sometimes observable, but they were seldom important 
symptoms ; occasionally, however, the delirium and excitement 
became more strongly marked, the patient was wild, excited, and 
with difficulty controlled and kept in bed. It was only, however, 
in a very few instances of any form of the disease, that the re- 
straint of the strait-waistcoat was required. I have myself seen 
it employed in but a very few cases all together, as will be subse- 
quently mentioned, but not in the algid form in more than one 
or two instances. In one of these cases, the patient, a young 
man, was taken ill on December 12th, 1857, and admitted on 
December 15th, with no very remarkable symptoms beyond epi- 
gastric anxiety, moderate pyrexia, and towards evening a tend- 
ency to delirium. On the 16th, he was observed at the hour of 
visit to have passed into a profoundly algid state, the surface 
being livid, the extremities cold and blue, and the breath and 
tongue very cold ; the eyes were injected ; the pulse was small 
and feeble at 88. Abundant black vomit had taken place, and 
black dejections passed per anum. I found him dead on the 
morning of the 17th, with the pillow, bed, and bedclothes pro- 
fusely stained with black vomit, which had issued in a torrent 
from the mouth and nose. He had been delirious and uncon- 
trollable, and the hands were strapped together. 

Where the whole aggregation of symptoms characterizing the 
algid form was of almost necessarily unfavorable augury, it is 
difficult to assign any special importance to those in question. I 
think, however, that I have observed that such cases as were at- 
tended with delirium and other symptoms of cerebral excitement 
were more rapidly fatal than those in which such symptoms were 
not presented. 

As will be seen from the records of our post-mortem researches, 
17 



258 YELLOW FEVER. 

the anatomical states of the cerebrum and its appendages were 
opposed to the supposition of inflammatory action as a cause of 
cerebral excitement or other such symptoms during life. Well 
marked inflammatory states of the brain and its membranes I 
have not myself met with ; and though slight congestions and 
slight serous effusions were frequent enough, they did not appear 
to have any constant or necessary relation to the symptoms of 
nervous excitement observed before death. 

As bearing directly on this part of the subject, I may briefly 
allude to the following results. I have made careful inspection 
of the cerebral substance, and the membranes of the brain, in a 
case presenting delirium during life ; and I have found an entire 
absence of congestion of the cerebral substance, and of serous 
effusion on the surface of the hemispheres or in the ventricles. 
On the other hand, distinct evidences of congestion on the sur- 
face of the ventricles, the cerebral substance on section showing 
the sable condition, and slight effusion of serum, sometimes of a 
slightly straw color, at other times of a bloody tinge, have been 
present in cases which, during life, exhibited no abnormal symp- 
tom whatever referable to the cerebrum. 

Gastric phenomena, with anxiety and depression. — Under this head 
may be comprised a peculiar and very indescribable set of symp- 
toms, half moral, half physical. These symptoms were chiefly 
referable to the epigastrium; they may be said to have been 
made up of a sense of uneasiness, anxiety, and apprehension, 
with a sinking feel, occasionally combined with nausea, and 
sometimes with pain more or less severe, but pain was neither a 
constant nor necessary attendant upon the condition in question. 
The whole set of symptoms were referable to the epigastrium as 
their principal seat, and to this region the patient's chief suffer- 
ings were in almost all cases assigned ; they are comprised in the 
French term "Anxiete epigastrique" 

Practical physicians are, of course, familiar with the occurrence 
of symptoms of a somewhat similar character in various kinds of 
affections, especially in those attended with profound abdominal 
lesion ; but under no circumstances have I ever seen them deve- 
loped to anything like the same extent, or causing the same 
amount of distress to the patient, as in the several forms of 
yellow fever, and in none more so than in that now under con- 
sideration. 



FUNCTION OF RESPIRATION. 259 

State of the cutaneous surface. — I have already partly described 
the general condition of semi-cyanosis which was presented in 
this class of cases. In extreme cases, the face was livid and 
dusky, the lips bluish, the hands and feet livid and cold, and their 
integuments shrivelled and wrinkled. The skin was very fre- 
quently thickly covered with an eruption of purpuric spots, 
usually of from half a line to one, two, or more lines in diameter, 
of a darkish red color, not disappearing on pressure, and per- 
sistent from their first appearance throughout the subsequent 
course of the disease. We have remarked that the surface was 
cold, in many cases remarkably so ; there was also much depres- 
sion of the cutaneous vitality, the action of blisters being slow 
and often imperfect ; complete vesication it was sometimes found 
impossible to obtain. 

Absence of yellow discoloration of skin or conjunctivae. — As already 
stated, the absence of the symptom of yellowness of the skin, 
conjunctivae, and all other parts whatsoever, was sometimes com- 
plete throughout the whole course of the case during life : and 
even in some few instances, no traces whatever of yellowness 
could be detected in these parts after death. 

This latter, however, was decidedly an exceptional condition ; 
as it generally happened that, though during the entire course of 
the case, till the last few hours of life, there was a complete 
absence of yellow coloration in all parts, slight yellowness began 
to be visible in the conjunctivas a short time before death. In 
other cases, in which there was entire absence of yellow color in 
all parts during life, it made its appearance soon after death took 
place; in general being soonest evidenced in the conjunctivas, and 
then gradually spreading to other parts ; as a rule, the whiter 
and fairer parts soonest exhibiting the discoloration. It was 
sometimes confined to the conjunctivae exclusively; this was often 
enough the case during life, much more rarely so in the post- 
mortem state. I am not aware of any instance, either during 
life or after death, in which this coloration being exclusively 
confined to any one spot, it selected any other situation than the 
conjunctivae in which to be manifested. 

Function of respiration. — No appreciable lesion of this function 
was commonly present. The breathing was not infrequently 
somewhat quickened, short, and imperfect, and occasionally 
u thoracic," or limited chiefly to the thoracic walls; this was the 



260 YELLOW FEVEK. 

case principally in connection with the state of epigastric anxiety 
above alluded to. Cough, dyspnoea, or thoracic pain, I have not 
myself observed ; and this almost -universal absence of thoracic 
symptoms is not a little remarkable, more especially when we 
take into account, as will be subsequently evident, the consider- 
able amount of congestive lesions of the lungs so constantly 
found, as a post-mortem condition. Bloody sputa were pretty 
often observed in the algid as well as in the other forms ; but, in 
consequence of the numerous sources from which blood was 
exuded, it was often extremely difficult to determine whether the 
blood, came from the lungs or not. In some instances it un- 
doubtedly did. 

Function of circulation. — As a general rule, the vascular action 
was much below par in the algid form. I have observed cases 
in which the radial pulse was imperceptible for days; more com- 
monly, however, the pulse at the wrist, though excessively feeble, 
was not altogether obliterated, and by a delicate and practised 
finger it could be felt and counted. Its rate was variable, more 
commonly below than above 100 per minute. I have noted it at 
80, very fine, thready, weak, and. readily extinguishable, and at 
almost all intermediate rates to 120 with much the same characters. 

The cardiac action was very feeble. I have not observed any 
diminution in the relative proportions of the first and second, 
sounds of the heart; they were often diminished in tone and 
force, but preserved their relative characters of duration and in- 
tensity. I have not observed any want of accordance between 
the cardiac action and that of the arteries in the algid form ; such 
as I shall have to speak of subsequently, when treating of some 
of the other forms. In general, in this form, the radial pulse 
could be taken as a measure of the cardiac action ; when the pulse 
was feeble, the heart was likewise proportionately so. There was 
no exception to this rule, as far as my experience of these cases 
goes. 

Hemorrhagic phenomena in the algid form. — TVe may very 
properly consider this class of phenomena after those of the cir- 
culating apparatus. Amongst those most constantly present we 
may notice, in the first place, the purpuric spots already more 
than once alluded to; as far as I have seen, they were all but 
universally present in the algid condition. The exact period of 
their occurrence it was not possible for me to determine, as they 



HEMOEEHAGE FROM NOSE AND GUMS. 261 

were invariably present when the patients were admitted into 
hospital, and equally so, whether this happened at an early or a 
comparatively late period after the first seizure ; we may naturally 
conclude from this, I think, that they were developed at a pretty 
early stage of the disease. I have no record of any special cha- 
racter attaching to them ; they were, in all respects, precisely 
similar to the spots of such constant occurrence in the epidemic 
purpura hemorrhagica of Ireland, and so often presented in low 
states of the system in the typhus fever of Ireland, interspersed 
with the true maculae of that disease. I have already specified 
their size at from half a line, to one, two, or more lines; some- 
times, but not very commonly, larger irregular patches of purpura 
of a few square lines in extent were observable. 

This occurrence of purpuric spots was very much, if not alto- 
gether exclusively, confined to the algid cases ; at least, I have 
not myself observed it in any of the other forms ; it was unques- 
tionably a symptom of very bad augury ; but as they presented 
themselves in connection with phenomena not one of which 
almost admitted of any other prognosis, purpuric spots could not 
be said to have any special value in guiding us to an opinion 
as to the probable issue of a case. 

Hemorrhage from the nose. — Epistaxis was a very constant phe- 
nomenon, either occurring singly, or, as was more commonly the 
case, being associated with bloody exudation from other parts. 
The amount of blood varied much, being sometimes only a slight 
oozing or draining from the nasal membrane, in other cases 
coming away in quantities varying from a few drachms to some 
ounces. I have not seen any case of profuse and uncontrollable 
hemorrhage from the nose, or one in which the bleeding from 
this quarter was in such quantity as of itself to threaten life. In 
smaller quantity, as a slight oozing, with the formation of bloody 
crusts on the alas of the nose, it was a very general symptom in 
the class of cases in question. 

Hemorrhage from the gums. — This, likewise, was a very constant 
source of hemorrhage, which, though never copious, was fre- 
quently continuous, and for this reason often the cause of a very 
considerable loss of blood. The hemorrhage came, either from 
the interval left between the teeth and gums by the detachment 
of the latter, which frequently took place, or from the superficial 
surface of the gums. In the latter case, the gingival membrane 



262 YELLOW FEVER. 

presented a thickened, soft, and spongy condition, similar to that 
so well exemplified in scorbutus. The bleeding was observed to 
come in several instances from the gingival membrane, on the 
internal face of the dental arch ; as well as from that on the ex- 
ternal. This hemorrhage from the gums was frequent in the 
other forms as well as in the algid, but I believe it to have been 
a constant phenomenon in this latter state. 

The tongue was very generally smeared with blood ; but I am 
not aware of any case in which the observation was actually 
made of hemorrhage from the lingual substance itself. The same 
is to be said of the conditions of the buccal membrane, the velum 
palati and all other parts within the mouth. It was not uncom- 
mon to find these parts smeared with blood, but it could be 
generally traced to the gums as the source from which it chiefly, 
if not exclusively, oozed. 

The blood commonly smeared all parts within the mouth, 
including the tongue, more or less tinging the saliva also; it 
likewise crusted in the form of blackish sordes on the teeth and 
gums, and in dry black masses on the lips and about the angles 
of the mouth ; and in the case of continuous oozing from the 
gums, it could be observed in some instances trickling from the 
corners of the mouth, and staining the lower parts of the patient's 
face, soiling and smearing his hands, the bedclothes, and all 
articles brought into contact with him ; and thus adding much 
to the appalling and horrifying features of this class of cases, 
already sufficiently dwelt upon. 

Hemorrhage from the lungs. — I have not witnessed a single 
instance in the algid form of haemoptysis as an isolated symptom. 
Sputa variously tinged and mixed with blood were frequently 
brought up, but from what has been just said of the manner in 
which the oozing from the gums gave a bloody tinge to all parts 
and structures within the mouth, it will be understood that, in 
the absence of distinct pulmonary hemorrhage, which I have not 
myself seen, it was difficult to determine whether the blood came 
from the lungs or not, 

Judging from the analogy of the cases in the other forms of 
the disease in which bloody sputa were ejected, and in which no 
oozing of blood took place from the gums, it may be readily 
assumed as probable, that in the general hemorrhagic tendency 
so well evidenced in most organs in the algid form, the bloody 



HEMORRHAGE FROM THE STOMACH. 263 

sputa were ejected from the lungs in this state in these varieties 
of the affection. Post mortem results make the supposition still 
more probable. 

Hemorrhage from the stomach. — Hemorrhage from the stomach 
in some form was a constant phenomenon in the algid state. It 
was most frequently presented as black vomit ; but all varieties 
were observable, from that of a slight admixture of coffee-ground 
matter, to the rejection of large quantities of blackish red, but 
otherwise little altered blood. I have said that gastric hemor- 
rhage was a constant phenomenon ; and this may be taken as a 
rule absolutely without exception in the algid cases, if we include 
the post-mortem results as well as the state before death. It 
sometimes happened that black vomit or other gastric hemorrhage 
was not observed up to the last moment of life, but that in the 
removal of the body after death, or by the expedient of making 
pressure with the hand on the abdomen, or in several instances 
without other causes than those acting within the body itself 
(development of gases and consequent increase of pressure on all 
internal parts) copious streams of blackish fluid or semi-fluid 
blood, or matter corresponding to black vomit, issued in quantity 
from the nose and mouth. In other and rarer instances it was 
only on opening the cavity of the stomach that the hemorrhage 
from this organ was detected. In all the algid cases, however, 
as far as my experience of them goes, gastric hemorrhage was 
present in some shape or other, either before or after death, and 
if in the former instance, invariably in the latter likewise. 

The period of occurrence of black vomit during life was very 
variable in this as well as in the other forms of the fever. It 
certainly observed no stated period in the algid cases, and seemed 
in no way necessarily to precede or follow the other hemorrhagic 
phenomena. It was occasionally amongst the earliest symptoms, 
while sometimes it almost immediately preceded death ; but even 
when profuse and continuous, it did not seem to have generally 
that immediately fatal influence often ascribed to it, and which, 
no doubt with justice, has caused it to be regarded as the pre- 
cursor of death in other epidemics. When early, I have known 
it to be followed by an interval of comparative tranquillity, and 
a slight alleviation of the other symptoms. I have known it to 
occur for the first time as late as the 6th, 7th, or 8th day, and 
yet to precede death by one, two, or more days. 



264 YELLOW FEVER. 

I have observed it in connection both with pyrexial and com- 
pletely apyrexial states. It has likewise occurred, and with ap- 
parently indifferent results as to amount and duration, in cases 
presenting marked gastric heat and pain, and " epigastric anxiety," 
and in other cases in which these symptoms were wanting alto- 
gether, or nearly so, and in which it appeared of an almost purely 
passive kind ; it has been present as a symptom more or less 
continuous for days together, and it has occurred at one particular 
period of a case, after which it did not return ; or it immediately 
preceded death, in which latter case it was often copious and pro- 
fuse. "With the exception of oozing from the gums, and the pur- 
puric spots and patches so frequently present in the algid form, 
as already stated, black vomit was sometimes, but only in very 
rare instances, the chief example of hemorrhage presented by 
these cases. 

Hemorrhage from the intestinal canal. — Blackish bloody dejec- 
tions, sometimes in considerable quantity, occurred in the algid 
cases. This form of hemorrhage was pretty often observed, but 
it was far from being a constant symptom, and was by no means 
so frequent as we would be led to suppose from the results of the 
examination of fatal cases, which in a very large proportion of 
the algid cases, constituting certainly the great majority of them, 
exhibited post mortem more or less extensive effusions of black- 
ened and otherwise altered blood throughout various parts, some- 
times through the entire tract of the intestinal mucous surface. 
While these appearances were nearly constant in the intestines 
post- mortem, we did not find that bloody dejections were very 
frequently present at any period of these cases during life, not 
even at that stage immediately preceding death. And while the 
escape of black vomit from the mouth and nose not infrequently 
occurred in the period shortly subsequent to death, both in those 
cases in which it was and in those in which it was not present as 
a symptom during life, I do not remember to have witnessed a 
single instance in which a similar escape of black or bloody 
matters occurred per anum after death. And yet, in some cases, 
the amount of intestinal hemorrhage was enormous; thus we 
have found the whole tract of the alimentary canal, from the 
stomach to the anus, literally filled with black, discolored, bloody 
matter, in some cases almost pure blackish blood. Indeed it 
would seem as if in some instances the last vital act was the sud- 



SECONDARY LESIONS OF THE ALGID FORM. 265 

den precipitation of the whole hemorrhagic force upon the intes- 
tinal surface, and the evacuation in this direction of a quantity 
of blood which, regarded simply as a hemorrhage, must have 
been in itself quite sufficient to produce immediate dissolution, 
from whatever part of the system it may have been poured forth. 
Such hemorrhage as that now alluded to must in all instances 
have occurred at only the shortest intervals before death ; and I 
have no doubt that in may cases death was actually caused in this 
way. 

Hemorrhage from the vagina. — This was a symptom pretty fre- 
quent in the algid form. A distinction requires to be made 
between those cases in which hemorrhage per vaginam occurred 
at periods not connected with the menstrual function, and in 
which the bleeding seemed to be the result of the general hemor- 
rhagic tendency in the system, and those cases, on the other hand, 
in which females were attacked with the disease at or about the 
time of the regular menstrual period. There can be no question 
as to the occurrence of the former kind of hemorrhage inde- 
pendently of the menstrual function, as it was known to take 
place at periods immediately succeeding the regular menstrual 
discharge. On the other hand, cases occurred in which it may be 
supposed that the regular period was accelerated or anticipated ; 
and more or less extensive hemorrhage per vaginam was the 
result, in some instances, at all events, as proved by post-mortem 
examination, having its seat in the uterine walls. 

It may be here mentioned, that an impression has often pre- 
vailed that vaginal hemorrhage has a salutary effect, and it has 
been supposed that its occurrence during the course of the fever 
improves the patient's chance of recovery. Certain it is that I 
have known recoveries attributed to the occurrence of this symp- 
tom by very intelligent persons. I cannot, however, say that 
what I have myself observed of such cases in any respect bears 
out the idea. I have met with several instances that would prove 
the contrary, if anything; and in the algid form it was in my ex- 
perience anything but a favorable sign. 

Secondary lesions of the algid form.— I have but rarely seen any 
instances of secondary lesions in connection with the algid form. 
Parotitis, and the erythematous affections so frequently met with 
in the other varieties, were almost entirely wanting in the algid 



266 YELLOW FEVER. 

cases. The system did not seem to retain sufficient reactive power 
to be able to produce or develop them. 



STHENIC FORM. 

In marked contrast to the algid form are the cases to which we 
have given the name of Sthenic. This class of cases is neither 
so numerous nor in some respects so formidable as the variety- 
just considered, nor again as that which we have denominated 
the Hemorrhagic form. And this observation holds good with 
regard to most of the great epidemics of yellow fever of which 
we have reliable accounts. I have seen this class of cases in 
the young, as in boys and girls of from 6 to 10 or 15 years of 
age ; but it was especially well marked in both sexes at the prime 
of life, and in persons with well developed muscular frames. 

Clinical history of the sthenic form. — The sthenic cases are in 
general characterized by well-marked febrile symptoms, severe 
and persistent headache, and much rachialgia at the outset, with 
subsequently a well-developed pyrexial state, high and full pulse, 
sometimes hard, and even occasionally thrilling and resisting, 
with flushed face and throbbing temples. The calor mordax is 
commonly everywhere perceptible, and the thermometer in the 
axilla indicates a considerable increase of temperature. 

Temperature indicated by the thermometer in the sthenic form — - 
This class of cases generally exhibits from the outset a remark- 
able elevation of temperature. It is common to find an increase 
of 3°, 4°, or even 5° Fahr., and in some instances an increase of 
nearly 7° has been observed. We have noted the thermometer 
in the axilla at 102,° 103,° 104,° and in some instances it nearly 
touched 105° Fahr. This limit I have not actually seen reached 
in any case, though the mercury in some instances rose consider- 
ably above 104°. (The instrument employed, an English one of 
the kind commonly used for hospital purposes, did not admit of 
more minute or accurate readings, than by whole degrees.) 

This form does not present any marked varieties, the cases 
having generally a pretty uniform course and very similar cha- 
racters throughout. A very remarkable circumstance about some 
of these cases, which I observed in the Lisbon epidemic, was the 
very unexpected manner in which death took place. (Case 2, in 
Table II., p. 40, Parliamentary Eeport.) 



TEMPERATURE IN THE STHENIC FORM. 267 

The pyrexial state is in general early developed. I have seen 
a case on the second day with hot skin, congested face, eyes 
suffused, the tongue dry, furred, and brownish, the pulse 104°, 
and the thermometer in the axilla marking 103° Fahr. 

This set of pyrexial phenomena often continues for days, some- 
times for six, seven, or more days, when a remission, or what 
should be more properly termed an apyrexial interval, more or 
less well-marked — that is, with a more or less complete cessation, 
or absence of febrile symptoms, supervenes. I have known all 
the characteristic phenomena of the fever, such as yellowness, 
black vomiting, and other forms of hemorrhage, to occur within 
this stage or period, when after seven, eight, or ten days, without 
a recurrence of anything like well-marked pyrexia, the case had 
apparently begun to pass into slow but regular convalescence. 
In other instances a true pyrexial state, but commonly with less 
well-marked characters, was re-established; subsequent to which, 
as will be afterwards considered, even a third stage was presented 
in some cases. 

State of the faculties in the sthenic form. — Smart delirium often 
accompanies these cases. This is to be expected when the head 
is hot, the face flushed, the temples throbbing, and other symp- 
toms of increased vascular action in the cerebrum are observable. 
Some few cases only occur in which delirium ferox, wild excite- 
ment, restlessness, and efforts to get out of bed require physical 
restraint. 

Lighter cases, with only wandering and muttering delirium at 
night, are more frequent. Sometimes, but rarely, the congested 
eye, with the well-known "ferrety" expression, the contracted 
brow, continuous muttering and delirium, never-ceasing tossing 
of the head from side to side, with increased heat and much pul- 
sation in the superficial vessels of the head and in the carotids, 
indicate that mischief has been going on within the cranial cavity. 
In such cases coma supervenes, the urine and feces are passed 
involuntarily, and death results. Various lesions of the brain and 
its membranes in connection with this state will be found de- 
scribed in the section devoted to the consideration of the patho- 
logical anatomy of the disease. (See particularly the case of a 
soldier of the Municipal Guard, Parliamentary Eeport.) 

Gastric symptoms. — Nausea, heat, pain, and anxiety in the 
epigastric region, are observable in many cases at an early period ; 



268 YELLOW FEVER. 

they are generally, however, but subordinate symptoms in the 
case, and by no means of the same marked character as in the 
algid form. 

State of the tongue.- — Various conditions of this organ are ob- 
servable. It is creamy, furred, or coated at the outset; dry, 
furred, and brownish in some few instances. As the case pro- 
gresses it becomes more dry and brown, sometimes assuming a 
contracted and pointed figure; the shape, color, and dryness then 
giving to it the peculiar and characteristic appearance known as 
"la langue perroquet," or parrot's tongue. 

State of the surface. — We have already considered the biting 
heat and the marked increase of temperature shown from an early 
date in these cases. The yellow coloration is perhaps better 
marked in the class of cases now under consideration than in any 
of the others. In some instances it is of a light lemon tint, 
general over the whole surface ; in others it is a pretty deep gam- 
boge; in others again it is of a more dusky hue, and verging 
upon orange. As far as my experience goes I cannot record any 
observation to show that there is any one specific period more 
than another at which the discoloration more generally supervenes. 
It seems to me to observe no particular period. I have seen it 
as an early symptom on the third day, slightly developed, but 
fully recognizable both in the conjunctivas and on the cutaneous 
surface generally. By the sixth day I have seen the skin in- 
tensely yellow in one set of cases, while in another it was only 
at this period that the yellow coloration began to appear slightly. 
I have seen a case up to the ninth day without the slightest yel- 
lowness. It has first presented itself during the continuance of 
the pyrexial state, and likewise at the apyrexial interval. It has 
appeared in connection with and during states of reaction, and 
likewise in states of sinking and depression. It has been found 
associated with quick pulse, hot skin, high thermometer, and with 
precisely opposite states. It has been absent when hemorrhage 
was present in some form or other, in this and the other varieties 
of the disease (its absence was most frequently observed in the 
algid form, as already fully explained) ; but I am not aware that 
yellow discoloration was present in any case in which hemorrhage 
of every kind was absent throughout from first to last. (Such 
cases, be it observed, were occasionally presented in hospital ; but 



FUNCTION OF CIRCULATION. 269 

whether they were to be regarded as examples of the fever is, to 
say the least of it, very doubtful.) 

Once well developed, the yellow coloration was very slow to 
disappear ; and in most cases it continued without very sensible 
diminution during the patient's stay in hospital while convales- 
cence was being established. 

I have observed its occurrence in the conjunctivae so early as 
the third day, with the pulse at 76, and but little heat of surface. 
In another case slight general yellowness was presented on the 
third day, the thermometer in the axilla marking 104° Fahren- 
heit, and the pulse being full, strong, and at the rate of 112 per 
minute. I have likewise observed it to occur on the fourth day, 
with the skin very hot, and the pulse 108, the tongue white and 
furred, and the patient delirious, but as yet presenting no form 
of hemorrhage. It was in another case presented first on the 
fifth day ; black vomit in small quantity, but quite characteristic, 
appearing about the same time. It was persistently absent in 
the remarkable case of a girl aged 13, admitted on the fifth day 
of her illness, with copious and characteristic black vomit ("noir 
de cafe") for two days, after which the symptoms gradually dis- 
appeared. 

In general, then, it may be stated that the yellow discoloration 
is not necessarily associated with any particular stage of the dis- 
ease, or with any special class of symptoms, those only excepted 
which belong to the hemorrhagic group. It seems to occur indiffer- 
ently in well-marked pyrexial and in apyrexial states, with all 
rates of pulse, and with all conditions of the animal tempera- 
ture, from 2° below, to 7° above the healthy standard. In the 
sthenic form, now under consideration, it is most commonly asso- 
ciated with an elevation of the thermometer, to the extent of 3, 
4, 5, or more degrees. 

Function of respiration. — I have but very little to observe with 
regard to this function, derangements of which are of rare occur- 
rence, though, as proved by post-mortem examination, engorge- 
ments of the lungs are common enough ; but, generally speaking, 
these conditions do not occur till very shortly before death. 

Function of circulation. — Quickened pulse, with increase of its 
volume, and more or less hardness and thrill, are commonly 
observable in the pyrexial state, which, in numerous cases, is 
frankly developed and established early, and exhibits a pretty 



270 YELLOW FEVER. 

high and continuous tension for several days, 5, 6, 7, or more, as 
the case may be. The cardiac action is likewise augmented, and 
in a proportionate degree in various instances ; the impulse being 
full and strong, and the sounds clear, full, and sometimes of a 
ringing character. 

Rate of the pulse in the sthenic cases.— The pulse, though often 
full and expanded, and occasionally hard and thrilling in this 
form, commonly ranges but little above 100 or 110 beats per 
minute. I have noted it in some cases at 112, 114, and in very 
rare instances so high as 120. In general, when the pulse runs 
above 115, the case passes into a low and typhoid state ; on the 
other hand, I have seen well-marked pyrexia with a pulse at 60. 
It has fallen to 100, 90, 80, and even 70, and in two instances to 
60, without very well-marked diminution of the other pyrexial 
symptoms; in these latter instances it has always retained its 
force and expansion. Thus we not unfrequently have the com- 
bination of a pulse at 70, 80, or 90, or in general terms under 
100, while the thermometer in the axilla shows a persistent tem- 
perature above 100° Fahrenheit. 

The following combinations of pulse rate and temperature were 
observed in the course of my investigations into the Lisbon 
epidemic; they are selected to show the absence of harmony 
and the frequent contrast presented by the two sets of pheno- 
mena : — 

TABLE OF PULSE RATE AND TEMPERATURE. 

, T .,, , .-no . C ii I the thermometer in axia ") 1n0 n -o 

1. In case with pnlse at 113 per minute, full, | gave ft temperature of } 102O F. 

<< « « 100O 

full " " 104O 

« » " 103O 

" " " 101O 

« « "• 103|o 

<< « « 1030 

u « « 104^02 

u « u 990 

« " " 100|O3 

From this table, already cited in a former chapter, it will be 
seen that the highest pulse rate and the highest temperature did 

1 These observations were made on the same case (one which passed into the 
hemorrhagic form) at intervals of two days. Calor mordax was present 
throughout in a marked degree. 

2 Calor mordax very marked. 3 Skin very hot. 



2. 


<( < 


1 100 


3. 


u c 


112 


4. 


<( ( 


' 104 


'5. 


(( ( 


' 92 


»6. 


u t 


1 100 


'7. 


U I 


1 104 


6. 


11 < 


< 100 


9. 


<( < 


84 


10. 


u I 


< 70 



HEMORRHAGES IN STHENIC FORM. 271 

not correspond. On the contrary, the highest pulse at 113 had 
only a moderate degree of elevation of the thermometer, 102° ; 
while the pulse at 100 gave the highest temperature, and the 
lowest pulse rate, that at 70 beats per minute, was attended by 
calor mordax and an elevation of the thermometer to 100J°. 
There was, therefore, no constant uniformity of relation between 
the two sets of phenomena. 

Hemorrhages in the sthenic form. — Generally speaking, this class 
of cases is attended by hemorrhages from one or more parts or 
organs. The hemorrhages are, however, not so profuse as in the 
algid form, nor so numerous as in the next variety, which we 
have designated the hemorrhagic form par excellence. 

Hemorrhages from the eyes.— Bright pink coloration of the con- 
junctivae, a symptom of very striking character, is occasionally 
observable. Minute vascular injection is a much more common 
symptom, and in some of the worst cases this is accompanied by 
a kind of hemorrhagic weeping from one or both eyes. 

Hemorrhage from the nose, mouth, gums, &c. — These hemorrhages 
are occasionally observable in the sthenic form, but not by any 
means so constantly as in either the algid or the hemorrhagic 
varieties. Bleeding from the gums, in particular, is a far less 
common symptom in the sthenic than in the algid form, in which 
latter I believe the spongy and scorbutic state of the gingival 
membrane is, as I have already stated, all but constant. 

Hemorrhage from the lungs. — Hemorrhagic sputa are not un- 
common in this class of cases, and by reason of the frequent 
absence of the bleeding from the gums, the pulmonary hemor- 
rhage is more readily recognized as such than in perhaps any 
other form of the disease. 

Hemorrhage from the stomach. — Characteristic black vomit, both 
in the form of " noir de cafe," or coffee-grounds, and with the 
more distinct appearances of blood slightly altered, is observable 
in the sthenic cases. But I believe I am justified in saying that 
this is the class of cases which more frequently than any other 
presents a total absence of this symptom during the greater part, 
if not, as in some instances actually is the case, during the whole 
course of the disease. But, as in almost all the cases of this and 
the other forms of the fever which do not present black vomit 
during life, I do not know, from my own experience, of a single 



272 YELLOW FEVEE. 

instance in which after death the stomach did not present more 
or less of hemorrhagic effusion in some form. 

Hemorrhage from the bowels. — This, never a constant symptom 
during life in any of the forms of yellow fever which I have 
witnessed, is rare and exceptional in the sthenic cases. Hemor- 
rhages from the intestinal surface are observable post-mortem, 
but far less commonly, and in general much less in quantity than 
in the other varieties. 

I cannot speak of any other form of hemorrhage in the sthenic 
cases but as of most rare and exceptional occurrence. There 
seems to be a complete absence of any tendency to cutaneous 
hemorrhage, or the development of any form of purpuric spots 
or patches ; in which particular these cases contrast in the most 
marked manner with those of the algid form. The sthenic cases, 
it may be said, present an entirely normal state of surface, setting 
apart, of course, the yellow discoloration. 

It is in this class of cases, I believe, that recovery is most 
frequent, and that the therapeutic measures employed are really 
efficacious and attended with manifest benefit. 



HEMOEKHAGIC FOEM. 

Next to the algid form, the cases to which we have given the 
designation of " Hemorrhagic" par excellence, are those which pre- 
sent the most characteristic, appalling, and impressive features of 
the disease. 

Gastric phenomena. — Epigastric anxiety, with or without heat, 
and pain on pressure in the epigastrium, is frequently well marked 
in the hemorrhagic cases. I have observed it in males, but more 
characteristically, I think, in females. In the latter it is often 
attended with sighing, sometimes weeping, nervous apprehension, 
and other symptoms to which we would, at other times, apply 
the term hysterical. 

The great and leading feature of these cases, entitling them to 
separate consideration under this distinct head, is the tendency 
to profuse simultaneous effusions of blood from various parts 
and organs. It is true that we occasionally have hemorrhages 
from the same parts, and even in extreme instances to the same 
extent in the other varieties of the disease ; but in this great 
group of cases there is a remarkable tendency to the profuse and 



HEMOERHAGIC FORM. 273 

simultaneous issue of blood from almost all parts that can possi- 
bly be the seat of hemorrhage. Thus this class of cases differs 
from the others in the frequency, the variety, and the combina- 
tion of the sources of the hemorrhages more than in the charac- 
ter or degree of any one of the bleedings which takes place. 
Black vomit, for instance, may be, and, unquestionably, often is, 
as profuse, as characteristic, as persistent, and in every respect 
as well-marked a symptom in the algid or the sthenic cases as in 
the hemorrhagic. But in this latter form, when the hemorrhagic 
tendency once declares itself, hemorrhage is never single, nor from 
any one source or organ only. Black vomit is combined with 
profuse intestinal hemorrhage, and with vaginal hemorrhage in 
females, with bleeding from the nose, the mouth, and the gums, 
and hemorrhagic sputa from the lungs, with bleedings from the 
eyes and eyelids, occasionally from the ears, and from several 
parts of the cutaneous surface denuded of epithelium by vesica- 
tion or otherwise. Any accidental abrasure in fact gives rise to 
bleeding more or less profuse. 

Such are the hemorrhages presented during life, often simulta- 
neously, and, as if having an origin in the one common vascular 
impulse, directed simultaneously upon all available points of the 
system from which blood can issue forth. 

But the hemorrhagic tendency is still further shown on post- 
mortem examination : — (1.) The cutaneous surface is surcharged 
with blood, as is evidenced by minute universal vascularity, and 
deep purplish-red hemorrhagic staining of the face, cheeks, back 
of the neck, chest, abdomen, and extremities ; universal tumes- 
cence and prominence of the superficial veins are likewise con- 
stantly observable. (2.) The brain, on its surface, in the ventricles, 
and throughout its substance, as well as in its membranes, gives 
evidence of the general vascular lesion. The base of the cranium 
and the ventricles contain bloody serum in greater or less quantity; 
blood appears on the lower sections also, and under the membranes. 
The sinuses and the cerebral vessels are gorged with blood. The 
rachidian venous system and the membranes of the spinal cord 
are occasionally extremely gorged with blood to the lowest point 
of the vertebral canal. 

The stomach and the entire intestinal tract are often filled with 
slightly altered black blood ; and, in a word, a universal san- 
guineous engorgement of all internal parts and organs exists in 
18 



274 YELLOW FEVEK. 

combination with more or less profuse parenchymatous and 
superficial hemorrhagic effusions. 

Clinical history of the hemorrhagic form. — In some cases the dis- 
ease presents the form now under consideration from a very early 
period after the development of the pyrexial state. In other 
instances the sthenic form is that first developed, and the cases 
subsequently assume the fully marked hemorrhagic type. I 
have observed this in the hemorrhagic form in both males and 
females; amongst the latter in a remarkable degree in those of 
extreme obesity. I have not observed it in the very old, nor, 
again, in the very young; and if the cases I have met with can 
be taken as a guide, it would seem to me to be in more or less 
direct connection with full and plethoric habits of body, and with 
the middle periods and most vigorous years of life. Most com- 
monly this class of cases is fatal at an early period — within five 
to seven days ; more rarely the system resists the depression 
which results from the profuse hemorrhages, and the cases then 
assume a low typhoid type of Continued fever, which sooner or 
later proves fatal. In one way or another (most usually as the 
immediate result of the hemorrhages) the patients are lost in this 
form of the disease, and that without its being possible, by any 
therapeutic means which medicine affords us, to arrest their 
progress or modify their course in the smallest degree. Disease 
in one of its most appalling forms holds its sway throughout, and 
art stands helplessly by ! 

A very remarkable feature in this class of cases is the peculiar 
smell which emanates from the patient; it is partially that of 
blood, but has another entirely peculiar character which I cannot 
describe, and can find no parallel for. In my experience it was 
always a fatal sign, even though appearing some days before 
death, and when the patient for the time seemed slightly im- 
proved in condition. I have observed this odor occasionally, but 
never quite characteristically, in the algid form, and even in the 
sthenic and purpuric cases in which any one variety of hemor- 
rhage was present to a profuse extent. But in no class of cases 
has it presented the same character of intensity as in the hemor- 
rhagic form. 

Condition of the surface. — Yellowness of the conjunctivas and 
the Cutaneous surface generally is usually an early and pretty 
well marked phenomenon. I can verify the statement, that in 



STATE OF THE FACULTIES. 275 

this form the yellow coloration constantly appears during the 
primary pyrexial state and while it is at its height, with the 
pulse over 100, and the thermometer in the axilla registering 
101°, 102°, 103°, or even 104°. It is, on the whole, not so vivid, 
nor, perhaps, generally so well marked as in the sthenic form, 
and in the later periods of the cases, and oftener after death, is 
not observed, and in parts is completely obliterated by the pur- 
plish red hemorrhagic staining and the minute general vascularity 
and venous turgescence already spoken of. 

State of the temperature. — The thermometer indicates generally 
a- less considerable elevation of temperature in the hemorrhagic 
than in the sthenic cases. I have observed the pulse at 92° and 
the thermometer at 101° Fahr. in a most characteristically well- 
marked hemorrhagic case. The pulse subsequently rose to 100° 
and 104° in the same case, with elevations of the thermometer to 
103J° and 103° respectively, calor mordax of the skin being 
present to a most marked extent. I do not, however, think that 
the temperature is generally so high in this class of cases. I 
believe that, as a general rule, the temperature in the hemor- 
rhagic cases is some 2° Fahr. under that in the sthenic form. 
The transition from the sthenic to the hemorrhagic form is some- 
times marked by a diminution in the rate and volume of the 
pulse, and a lowering of the thermometer ; the patient's strength 
sinks visibly at the same time, and in some cases a clammy sweat 
bedews the face for one or two days. This state of things is fol- 
lowed by, as it were, an explosive and universal lesion in the 
vascular system, leading to profuse hemorrhages at all available 
points of the cutaneous and mucous surfaces. 

State of the faculties. — In respect to the state of the perceptive 
or sensitive faculties, the condition of the hemorrhagic cases does 
not differ remarkably from that observable in the sthenic. When, 
however, the hemorrhagic tendency is about to be developed, the 
patient sinks visibly, the face becomes congested, the eye suffused 
and vascular, and there is more or less indication of disturbed 
cerebral circulation, as evinced by heat, throbbing, and pain in 
the head, heaviness or drowsiness of the patient, a muttering 
delirium and a semi-comatose state. 

Complete absence of sensation with true coma I have but very 
rarely observed. In one marked case, the patient lay prostrate 
in bed in a low muttering delirious state, being occasionally vio- 



276 YELLOW FEYEE. 

lent, and requiring the restraint of a strait-waistcoat to retain 
him in bed ; he lay with his eyes closed , his mouth partially open, 
never sleeping, and with an unceasing rolling and tossing motion 
of the head from side to side on the pillow, which continued with- 
out intermission day and night for nearly forty-eight hours, when 
death put an end to the melancholy spectacle. 

Though true coma is rare, as is indeed any profound cerebral 
lesion, various lesser affections, accompanied with muttering de- 
lirium, restlessness, and other effects of cerebral excitement, are 
sufficiently common in this form of the disease. 

Function of respiration. — The clinical characters connected with 
the functions and organs of respiration present nothing of a posi- 
tive kind, and hardly require special notice. Sanguineous en- 
gorgements of the lungs are commonly, indeed it may be said 
universally, found to be present in the post-mortem examination 
of these cases. Yet we have little or no distinct record of cor- 
responding clinical symptoms ; this is, I conceive, to be explained 
by the hemorrhagic engorgement of the pulmonary structure 
taking place most frequently only at short intervals before death. 

Hemorrhagic sputa are commonly observable ; but they become 
a very subordinate feature by contrast with the hemorrhages 
from the other sources, which are so frequent and copious. In 
such a combination of hemorrhagic effusions, as from the nose, 
from the gums and other parts of the mouth, and from the 
stomach, it would be exceedingly difficult, if not practicably im- 
possible, in the great majority of instances, to establish the posi- 
tive diagnosis of true pulmonic haemoptysis. 

Sputa with blood and mucus variously mixed, were constantly 
ejected ; but I have not myself determined the occurrence of 
haemoptysis to anything like a considerable or formidable extent 
in any one instance, and I am not aware that anything of a more 
positive character can be stated from the results of the inquiries 
and observations of other investigators. 

Function of circulation. — This is the part of the system upon 
which, as it were, the whole force of the disease is precipitated in 
this class of cases. 

State of the Pulse. — I have nothing to record of a characteristic 
or peculiar kind in reference to the pulse. It is commonly less 
frequent than in the sthenic form, but has perhaps more of ful- 
ness and expansion, while its force is less. 



COMBINED HEMORRHAGES. 277 

I have carefully noted the condition of the pulse in numerous 
cases, and in no one instance have I met with anything approach- 
ing to the dicrotous character either before or during the height 
of the hemorrhagic invasion ; and that it was a very rare condi- 
tion in the Lisbon epidemic is evidenced by the circumstance that 
in the large experience of Dr. May Figueira, one of the physicians 
to the Desterro Hospital, it was presented but once ; this observer 
could call to mind only one single case in which the pulse pre- 
sented a well-marked dicrotous beat. 

The rate of the pulse is variable ; it is commonly over, rather 
than under, 100 per minute. It is most generally full, soft, and 
expansive, and wanting in force and rebound. These, it will be 
observed, are not very positive characters ; but no such were 
presented in the great majority of cases observed by me. 

The pyrexial state is evidenced more decidedly by the state of 
the thermometer, which is usually over 100° Fahr. There is 
much variety in this respect; but what is important, and what 
can be positively stated, is that the hemorrhages occur during 
the pyrexial period, and with elevation of the pulse, and the ther- 
mometer above the standard. Thus we have seen them presented 
with characteristic force and intensity, while the pulse was at 100, 
and the thermometer in the axilla stood at 103J° ; but this latter 
is unquestionably an exceptional elevation for the form of the 
disease now under consideration. 

Hemorrhages. — "We have already given a summary of the va- 
rious forms of hemorrhage met with in combination in this form ; 
and it will not be necessary to go into any considerable detail 
upon the subject in this place. The remarkable character of this 
general hemorrhagic lesion consists in the amount, the variety, 
and the combination of the several kinds of bleeding which take 
place. 

We have observed in combination in a single case — 

1. Hemorrhage from the eyelid (from accidental abrasure, but 

in unusual quantity). 

2. Hemorrhage from the nose. 

3. u " gums. 

4. Black bloody crusts on the tongue. 

5. Hemorrhage from the stomach, black vomit. 

6. " u the intestines. 

7. " " blistered surfaces. 



278 YELLOW FEVER. 

8. Hemorrhage from the vagina was superadded in some eases 
in females. 

Hemorrhagic weeping from the conjunctivas has been observed; 
I have myself seen but slight oozing of blood from the ears (and 
always in connection with parotitis, to be subsequently spoken 
of), but distinct hemorrhage in this quarter has been met with. 
Hemorrhage from the penis has likewise been known to occur ; 
but I have not witnessed well-marked examples of this variety 
of hemorrhage ; at least, not in sufficiently large quantity to be 
specially noticed as such. Mixed with the urine in variable 
quantity blood has been by no means infrequently observed, 
giving the smoky or the distinctly blood-colored tints to that 
fluid. 

T have witnessed hemorrhage to some inconsiderable extent 
from the internal surface of an abscess on the abdominal walls, 
from which the contained purulent matter had been evacuated. 

Hemorrhages from the nose and gums are frequent, and, with 
respect to the latter, are often in considerable quantity. I believe 
that I have likewise witnessed hemorrhages distinctly beneath 
the tongue, but it was in most instances next to impossible to 
decide whether the bleeding came directly from this organ, owing 
to the continuous escape of blood from the gingival membrane, 
which stained and coated every part within the mouth. The 
tongue is bathed in bloody saliva, is blood-red at the tip and 
edges, and perhaps, also, crusted with blackened blood on the 
dorsal aspect. With the yellow coloration of the conjunctivae 
and surface ; generally congested if not sanguineous eyes ; black 
blood-crusts on the lids or other parts accidentally abrased ; the 
nose and angles of the mouth and the teeth and the borders of 
the lips crusted with blood, if not still dribbled and stained with 
freshly flowing blood ; the tremulous tongue, when protruded, 
blood-red at the tips and sides, and thinly covered with blackish 
blood crusts on its dorsum; a combination of symptoms is pre- 
sented, of as striking a character as can well be found in all the 
long category of disease. 

Black vomit. — This symptom, or as I should prefer to designate 
it in this class of cases Hoematemesis, is very constantly present^ 
quite invariably so, if we include the condition of things found 
post mortem. 

The noir de cafe : or coffee ground vomiting, is commonly super- 



PURPURIC FORM. 279 

seded in this form by a true hemorrhage from the stomach ; black 
blood in quantity being ejected from the mouth daring life, and 
found post mortem in the stomach, and often throughout the 
whole intestinal canal. 

Black dejections are not so generally present during life as 
might be supposed from the state of the intestinal surface found 
post mortem. I have already remarked on this in connection 
with cases of the sthenic form, in which the presence of black 
matter in the intestines after death was not always preceded by 
black dejections during life. The connection of these two ap- 
pearances is more common in the hemorrhagic form ; but is yet 
far from being constant. On the whole, black dejections are in 
this, as in the other forms, far less frequent than black vomit, or, 
indeed, than any other variety of hemorrhage. 

We have already remarked upon the constantly fatal character 
of this form of the fever. The universality of the vascular lesion 
and the profuseness of the hemorrhage at once explain this re- 
sult, and likewise make evident the almost utter futility of all 
therapeutic means in dealing with so profound and extensive an 
affection. 

Death seems to take place in many instances directly as the 
result of the hemorrhages, and generally within a short period — 
twenty-four to thirty-six hours after they have set in. Some few 
remarkable cases, endowed apparently with a singular tenacity 
of life, resist for a longer period. Two or three cases only fell 
within my experience which lived quite through the hemorrhagic 
period. These cases assumed a low typhoid form of Continued 
fever, with great prostration of strength, quick feeble pulse, and 
calor mordax of skin; the thermometer was up to 103° Fahr. for 
days in one remarkable case, with corresponding biting heat in 
the skin. They all died within a week or ten days from the 
cessation of the hemorrhages and the first appearance of the 
typhoid symptoms. Hiccup becomes a very distressing and un- 
controllable symptom in some of these cases, adding much to the 
patient's sufferings. 

PURPURIC FORM. 

By this term I propose to designate certain cases which, though 
not frequent in any epidemic, are of remarkable interest in some 
points of view. 



280 YELLOW FEVER. 

I have already pointed out, in speaking of the algid form, the 
constant and indeed invariable occurrence, in that class of cases, 
of innumerable purpuric spots and small purpuric patches on all 
parts of the surface. In truth, the algid form was in itself a true 
purpuric disease; but the algid phenomena predominated, and 
hence are entitled to be considered as distinguishing that variety 
of the fever. 

The cases I have denominated purpuric, do not however belong 
in any respect to the algid form ; the pyrexial state is well marked, 
the pulse frequent, and the skin hot, the tongue dry, brown and 
furred or fissured, while the conjunctivae and the general surface 
are intensely yellow. 

The following is a brief and concise statement of the chief 
features of the most remarkable of the purpuric cases which came 
under my observation. The patient, a man aged 40 to 45, had 
presented the usual history and symptoms; on the eleventh day 
bleeding from the gums still continued, the skin was hot and 
everywhere yellow, as were likewise the conjunctivae ; the day 
following a large purpuric patch, four to six inches square, was 
observed in the left axilla, spreading to the front of the chest, 
which further presented several smaller patches of similar color, 
extending to and a little beyond the mesian line. Slight but 
manifest oedema of the whole anterior part of the chest was ob- 
servable. The skin was hot, the pulse only 70, but full. 

Two or three days subsequently a similar but much larger 
patch appeared in the right axilla, which eventually occupied the 
whole lateral aspect of the right side of the chest, and extended to 
within a short distance of the crest of the right ileum ; it likewise en- 
croached upon the back. The color of the patches varied from 
a reddish to a bluish purple ; the borders were gradually shaded 
off in successive tints, till the ordinary yellow surface was reached 
on either side of the patch. The pulse has fallen to 52, the tongue 
was moist, but the skin still remained hotter than natural. 1 The 
patient was still very yellow. Ascites subsequently appeared : 
the case lingered out for more than ten days after the first obser- 
vation of the purpuric spots, and ultimately died. 

1 I have unaccountably mislaid the notes of the thermometric observations, 
frequently taken during the course of this very interesting case, but my recol- 
lection is distinct of the fact that the temperature was throughout above the 
healthy standard. 



TYPHOUS FORM. — TYPHUS ICTERODES. 281 

The patches observed in this remarkable case were precisely 
similar to those so often seen in the epidemic purpura hemor- 
rhagica of Ireland. Putting apart the yellow coloration — and 
if we bear in mind the presence of bleeding from the gums, and 
the spongy state of the gingival membrane — in both diseases the 
parallel was very close indeed. 

This class of cases is of great interest in connection with the 
question of the cause of the coloration in yellow fever. The 
purpuric patches are manifestly caused by subcutaneous effusions 
of the coloring matter of the blood ; and all varieties and shades 
of color and tints are observable, from bluish purple to yellow at 
the circumference of the patches, where the morbid tint passes 
into that of the surrounding skin. 

TYPHOUS FORM. 

I have given special attention to the study of the several 
clinical forms in which yellow fever presents itself, from a con- 
viction that much of the discrepancy and apparent conflict of 
medical authorities in their descriptions of visitations of the same 
epidemic disease, at various times and places, has arisen from 
want of due discrimination of its leading characteristics and 
salient features. 

The clinical phenomena which characterize disease, whether 
endemic or epidemic, seldom observe a constant and invariable 
relation to each other. And hence it is, that while in a given 
epidemic, in a given locality, at a given time, one set of pheno- 
mena will be prominent, if time, place, or other circumstances be 
changed, the disease will present in salient relief another train of 
symptoms, with perhaps a totally different clinical cachet, dis- 
playing another order of phenomena, and being wanting in 
those which were described as all but essential to it in its former 
phase. 

To the investigators of typhous epidemics the force of these 
observations will be at once apparent. And if their bearing on 
the study of yellow fever epidemics be not equally apparent, it 
is perhaps because that of the numerous inquirers into the clinical 
history of this malady, so few have had an opportunity of wit- 
nessing its invasions under varieties of place, time, and other 
circumstances. 



282 YELLOW FEVER. 

The observer and historian of an epidemic of yellow fever, in 
which the typhous form was predominant, would hardly recog- 
nize as an accurate portraiture of the disease the description of a 
visitation in which the algid was the prevailing type. Nor, again, 
would this latter form be familiar to one who had studied the dis- 
ease as a sthenic fever. 

The prevailing types in the Lisbon epidemic of 1857, were 
unquestionably those I have described as the algid, sthenic, and 
hemorrhagic. Some few cases presenting a typhous character 
were, it is true, occasionally observed ; but in no way would this 
fever admit of being reduced to the type of the typhus icterodes 
of authors. 

Typhous characters. — Typhous phenomena were presented in 
two orders of combination in the cases observed by me. In one 
they appeared as the primary and essential characteristics of a 
case from an early period of the febrile invasion. Stupor and 
nervous depression, with the peculiar sunken expression of the 
face, the suffused eye, the flaccid state of the limbs, dorsal decu- 
bitus, feeble muttering delirium, and the other well-marked 
typhous characteristics, all became superadded to the hemor- 
rhagic phenomena, and the yellow coloration of the skin and 
conjunctivas, which gave the special cachet to the disease. A case 
with these characters might be readily likened in external ap- 
pearances, and indeed strikingly so, to the forms of typhoid pneu- 
monia with jaundice, familiar to the Irish practitioner. 

I must, however, here remark that in my experience of the 
late Lisbon epidemic, cases corresponding to the foregoing de- 
scription were of extreme rarity. They were, in fact, so few as 
to form no practically important part of the epidemic. 

The second order of association in which typhous characters 
were observed was, that in which cases having passed through 
the various stages of the sthenic or the hemorrhagic forms, glided 
insensibly into a typhous condition on the cessation of the hemor- 
rhagic tendency. In these cases, the hemorrhagic diathesis gave 
way to, or became supplanted, as it were, by the typhous type of 
disease. In no instance have I observed cases of the algid form 
to undergo this transition ; this is intelligible from what has been 
already stated respecting the constantly fatal character of the cases 
under this head, which did not live to a period in which a typhous 
stage would have been possible. 



CONDITIONS COMMON TO YELLLOW FEVER. 283 

The typhous condition, when developed as a secondary stage, 
presented the usual characteristic phenomena, with stupor and 
nervous depression. The pyrexial state was continuous, the 
pulse very quick but feeble, and the thermometer indicated an 
increase of temperature to the extent of four or five degrees. 
These cases proved fatal in all the instances which I had an 
opportunity of observing. Careful examinations were made post- 
mortem, more especially through the intestinal tract ; but inva- 
riably with the result of showing a complete absence of follicular 
lesion in any portion of the mucous membrane. 

CONDITIONS COMMON TO ALL THE FORMS OF YELLOW FEVER. 

Several phenomena may be considered to be common to all the 
forms of yellow fever. 

A remarkable condition, which was specially noticed in the 
Lisbon epidemic, is that of a costive habit of body, which, it is 
to be observed, was by no means confined to those attacked by 
the fever. Indeed, the lamentably negligent and unclean habits 
of the population in several thickly inhabited districts of that 
city, furnished abundant ocular demonstration of the general 
prevalence of the condition alluded to. Thus, in numerous main 
and lateral streets and passages of the quarters Alfama, Mouraria, 
and Bairro Alto, the human dejecta with which the pavement was 
thickly strewn furnished to the passer-by, at every step, unceas- 
ing opportunities for koprological studies, to which his attention 
became thus forcibly and unavoidably drawn. From observa- 
tions thus made through no inconsiderable extent of the most 
densely inhabited parts of the city, the conclusion is of necessity 
drawn, that a costive state of the bowels is, if not a universal, at 
least a very general characteristic of the Lisbon population. It 
will not be unfamiliar to medical observers, especially to those 
acquainted with the camp life of different nations, that marked 
characteristics may be recognized in the koprological phenomena 
of different peoples, dependent on the nature of the food used by 
them, the modes of using it, and the manner of cooking it. 

Pretty extensive inquiry amongst medical practitioners, com- 
bined with personal observation, confirms the above conclusion. 
In relation to the causation of the epidemic, this condition, which 
is not a temporary one, can only be considered as amongst the 



284 YELLOW FEVER. 

collateral adjuvant causes, and not as one of any special import. 
It cannot be doubted, however, that in many instances, a more 
than usually confined state of the bowels was known to precede 
the invasion of the disease. By some this state was regarded as 
an undoubted predisposing cause of yellow fever; while the 
opposite condition, or that of a relaxed habit of body, and even 
the presence of a slight amount of diarrhoea, was looked on as a 
salutary condition, if not as a preventive. 

As an indication for treatment, this condition was so far re- 
cognized as a guide, that active purgation was, in a great number 
of cases, largely employed at the outset of the disease. I cannot, 
however, say that there is any reason, based on reliable evidence, 
for assigning to this mode of treatment any superiority over rival 
plans, equally largely in vogue with other practitioners. I am 
not aware that this condition has been noticed in connection with 
other epidemics of yellow fever. 

Renal function. — The various conditions of the renal secretions 
may be summed up as follows : Almost complete suppression of 
urine is observed in certain cases. In other instances, and this 
not unfrequently, the urine has been abundant, normal in specific 
gravity and reaction ; high colored or normal in this respect, 
often clear and transparent, and often of a rich straw or amber 
color : while at other times it is found highly loaded with lithates, 
and presenting the brickdust sediment, with more or less color- 
ing matter in different cases. Under other conditions, the urine 
is found coagulable by heat and nitric acid, and it is occasionally 
brownish-red, smoke-colored, or variously tinged, from more or 
less admixture of blood elements. 

I have not observed the specific gravity of the urine in any 
case to fall below 1011, or to pass much above 1030 ; in other 
cases, but certainly not with constancy, nor, in my experience, in 
any very large proportion of the cases, the peculiar reactions of 
the biliary coloring matters were detected. 

No deficiency of any of the normal constituents of the urine 
has been observed by me in any single instance (putting apart, 
of course, those cases in which there was a total or partial sup- 
pression of this secretion). Urea has been detected in abundance 
by the usual reaction with nitric acid in numerous cases. Nu- 
merous small cylinders of fibrine, with casts of tubules and 



STATE OF THE URINARY EXCRETION. 285 

detached epithelial cells, have been not ^infrequently detected by 
microscopic examination. 

The various and apparently opposite conditions of the urinary 
secretion just enumerated may, I think, be, generally speaking, 
referred to definite conditions and to different forms and stages 
of the febrile disease, with which, as it appears to me, they were 
associated not without a certain uniformity, nor without a relation 
by no means unintelligible to the physiological pathologist. 

Suppression of urine. — Partial or complete suppression of urine 
has not fallen under my observation except in connection with 
the algid condition, whether we regard it as a form or as a stage 
of the disease. In cases presenting the well-marked characteristics 
of the algid state more or less complete suppression of urine was 
usually observable on the patient's admission into hospital, and 
while life lasted. In fatal cases it was very common to find a 
small quantity of straw or amber-colored urine in the bladder. If 
reaction to any extent became established after the patient's ad- 
mission to hospital, urine was again secreted in variable quantity, 
and was passed usually voluntarily, occasionally involuntarily ; 
and, in a few instances, the introduction of the catheter was re- 
quired for its removal. 

Partial or complete suppression of urine in such cases seemed 
to stand in very intelligible relation with the generally depressed 
condition of the vital powers, and the stagnation of the circulation 
more especially, and was only one of several similar states of sus- 
pended action in the system. In a few instances albumen was 
found in the urine in connection with this depressed condition of 
the circulation. Thus in one instance, with the thermometer at 
96°, the pulse was observed to be 108, and two ounces of urine, 
specific gravity 1029, when coagulated by heat,, were found to 
contain 39 grains of albumen. This, however, was one of the 
semi-algid cases, in which reaction subsequently took place, for in 
two days afterwards the pulse rose to 140, and the thermometer 
in the axilla gave a pyrexial temperature of 102° Fahrenheit, 
while two ounces of urine, with a specific gravity of 1016, gave 
now but 19 grains of albumen. 

On referring to the results of the post-mortem examinations 
in yellow fever cases, it will be found that congestion of the kid- 
neys, in common with most other internal organs, was sufficiently 
often observed. Albuminuria under these circumstances must 



286 YELLOW FEVER. 

be regarded as only of the passive kind, and the result of a 
forced elimination through the urinary tubules by the vis a tergo 
of congestion in the parenchyma of the organs. 

Urine with excreta in excess. — This class of phenomena, accord- 
ing to the results of my observations, stood in direct connection 
with the development of the pyrexial state. Urine, with high 
specific gravity, 1025 — 30, and intensely acid reaction, straw, 
fawn-colored, or brownish-red, and with more or less abundant 
deposit of variously colored lithates, constantly attended the well- 
marked pyrexia of the sthenic cases. It was likewise observed, 
but not so commonly, in connection with the hemorrhagic form. 

The relation of these phenomena to increased tissue-metamor- 
phosis with calor mordax of skin, quick pulse, and elevated ther- 
mometer, was quite as marked, and as readily observable in the 
pyrexia of the yellow fever as in that of other febrile states, and 
manifestly depended on the same causes. Increased tissue- 
metamorphosis was progressing in the system, and its outward 
manifestations, constituting the elements of a true pyrexial state, 
were easily cognizable on search. This, it appears to me, is beyond 
question the true pathological connection or relation of these 
phenomena. 

Albuminous excretion uy kidneys.— Albumen was found in the 
urine in the following orders of association : — 

(a.) As the only abnormal element, and with or without other 
blood elements. 

(b.) In company with abundant deposits of lithates, with or 
without coexisting deposits of purpurine or other coloring matter 
in excess. 

(c.) In connection with biliary coloring matter, the presence 
of which was shown by the usual reagents. 

(d.) In connection with pyrexial states ; and 

(e.) In connection with apyrexial states. 

The quantity of albumen was sometimes very considerable, as 
much as twenty grains to the ounce of urine in some instances. 
In some cases it was a persistent condition for many days ; in 
others the quantity of albumen decreased rapidly, and finally dis- 
appeared. In one instance, the quantity fell in three days from 
about twenty grains to the ounce to about half a grain. Its rela- 
tion to, and connection with, a highly congested state of the 
kidneys was very obvious ; I am, therefore, disposed to regard it 



PAKOTITIS. 287 

as a manifest result of the passive congestion of the organs so 
constanly found in our post-mortem examinations ; if viewed as 
such, it loses any special significance in relation to the peculiar 
type of febrile action, of which it was, in fact, an accidental and 
not a necessary concomitant, though it may be said not an infre- 
quent one. It certainly had no relation to any condition of de- 
generation of the parenchyma of the organ, for none such was, 
as a rule almost absolute, ever found to be present; and it was 
usually associated with a high specific gravity of the urine, 
indicating and dependent on the continued excretion of the nor- 
mal elements in at least a normal amount. 

Excretion of coloring matter having the usual biliary reaction. — 
This is one of the most remarkable of the phenomena presented 
in the urinary secretions. It was neither a constant nor a very 
general condition ; but yet it has been sufficiently often observed. 
It was found in connection both with pyrexial and with apyrexial 
states, with and without deposits of lithates and coloring matter, 
and with or without albuminous excretions, as already noticed. 
The nitric acid test was that most commonly employed. It gave 
the usual appearance of iridescence, with finally the production 
of the dark olive green tint. With other reagents corresponding 
results were obtained. 

Parotitis. — This affection has been noticed in several epidemics 
of yellow fever ; it was amongst the most constant of the affections 
presented during the course of the yellow fever cases in the Lis- 
bon epidemic; it was presented in some instances singly in one 
parotid region; in others it attacked both sides. The amount of 
inflammatory action varied a good deal; in many instances it 
was limited in extent ; the heat, redness, pain, and swelling were 
moderate in amount, and caused the patient but little suffering : 
in other cases, on the contrary, a very violent inflammation 
attacked one or both parotid regions, which became enormously 
swollen, reaching occasionally the size of a large fist on either 
aspect of the face, rendering it impossible for the patient to open 
his mouth for days, and ending in profuse and exhausting sup- 
puration, or leading to the suffocation of the unfortunate patient 
from the pressure of the inflamed mass on the parts within the 
fauces. 

Leeching, with cooling applications, poultices, and the lancet, 
or the spontaneous opening of the swelling, gave various relief 



288 YELLOW FEVEK. 

in different cases. In some instances a bloody sanious matter 
was evacuated; in others, the parotidean swelling was the seat of 
no inconsiderable hemorrhagic oozing. It not unfrequently 
happened in these cases that the external auditory meatus was 
the source from which blood escaped ; and I may here remark 
that I have not myself witnessed any other form of hemorrhage 
from the ears, though I do not by any means desire to express a 
doubt of the possibility of such a hemorrhage independent of 
parotitis, instances of which have been reported to me. Such an 
occurrence is so far probable that it is fully paralleled by the 
hemorrhages from the eyes and other quarters not commonly 
the seat of exudation of blood. 

With the exception of the inflammatory processes developed 
in the cutaneous surface of the extremities as the result of 
excessive vesicative action, and sometimes leading to gangrenous 
destruction of the superficial parts, as elsewhere noticed, I have 
no other instances of secondary inflammatory action to record in 
yellow fever cases. 

An efflorescent rash has been described by some observers as 
making its appearance on the chest, and gradually extending 
over the abdomen and arms. On fine, delicate skins, rose-colored 
spots have been remarked ; but most of these appearances seem 
due to such causes as mosquito bites, which eventually become 
hemorrhagic points ; these must not be confounded with the 
purpuric spots and patches already described in connection with 
the algid form. 

Bloody furuncles have been found to occur in some epidemics, 
and seem to be regarded as sequelae of the disease. They are 
found upon the wrists, over the metacarpal bones, along the front 
of the legs, below the scapulas and over the hips, in the parotid 
region, and on the forehead and lips. They are said to occur in 
close proximity to the smaller arterial trunks ; they become 
tender and acuminated, and, if opened, discharge a curdy and 
watery sanies. These furunculi occasionally communicate with 
a deeper inflammation, leading to abscess with subsequently 
infiltration of pus and blood, and occasionally gangrene of the 
parts engaged. Dr. Blair speaks of the possibility of the occur- 
rence of similar furuncular action in internal organs ; but, except 
in the kidney, he does not appear to have actually met with any 



USE OF BARK, QUININE, ETC. 289 

analogous state. I have not observed any such conditions in 
my numerous examinations. 



TREATMENT. 

The treatment of the several forms of yellow fever resolves 
itself into the use of stimulants, counter-irritants, purgatives, 
including croton oil, and the employment of special remedies, 
such as quinine, bark, iron, &c. Blisters to the nucha, epigas- 
trium, insides of the thighs, calves of the legs, and dorsum of 
the feet have been constantly employed. Blisters to the nucha 
are of use in relieving the headache and other symptoms refera- 
ble to the head. Yesication of the epigastric region frequently 
produces marked relief of the epigastric pain, and of the symp- 
toms before mentioned under the term "epigastric anxiety." 
Blistering to the thighs and calves of the legs is employed as a 
means of stimulation in cases with much collapse and sinking. 
The application of mustard poultices is a popular remedy much 
in use, and as the reaction is low, the effect of their application 
is not felt at the time ; they are thus often allowed to remain on 
for protracted periods, with the effect of inducing very severe 
and extensive vesication in the parts after reaction has taken 
place. 

I have seen a condition approaching to gangrene, occupying an 
extensive surface of the anterior and posterior aspects of both 
legs in such cases, and likewise of the dorsum of the feet in 
others, as the result of incautiously protracted vesications. The 
amount of suffering thus inflicted on patients is often most severe 
and shocking. 

Frictions to the chest, abdomen, and legs with various medi- 
cinal substances were in common use in the Lisbon epidemic ; 
the tincture and decoction of bark were frequently thus used. 
Frictions with camphorated spirit were also much employed. 
Amongst the stimulants most constantly in use were wine, 
brandy, ammonia, and ether, all liberally exhibited as the urgency 
of the case required. A wine of strong body, and with a consi- 
derable percentage of alcohol, was much employed in hospital 
practice ; it was that known as " Lavradio." It was of the color 
of deep-bodied port, but combined with the port flavor somewhat 
of that of the claret grape; it was a sound, strong bodied, Pall- 
19 



290 YELLOW FEVEK. 

flavored, and rich wine. I have seen it exhibited to the extent 
of twelve ounces per diem. In many cases I would have myself 
employed wine ; brandy, and other stimulants with still greater 
freedom, but the general opinion was rather against unlimited 
stimulation; and it was likewise said to have been shown by ex- 
perience to be ineffectual when the more moderate use of such 
measures failed to produce reaction. I am not indisposed to re- 
gard this opinion as well founded. 

Use of bark, quinine, &c. — Decoctions of bark were constantly 
in use, with or without ammonia or other stimulants. 

Quinine has been much employed ; it is used both by the 
mouth and anus. Given by the mouth it may be prescribed in 
large doses, and in small doses it is used at the outset of the dis- 
ease, and in all stages up to the last. In the form of enema I 
have seen it administered to the extent of seventy-two grains, 
divided into four clysters, one of which was given every sixth 
hour. 

From my experience of this medicine, as administered in the 
epidemic we are now speaking of, I am far from being disposed 
to regard it as a drug upon which any reliance can be placed 
when exhibited during the course of the disease, The indica- 
tions for its use as an antiperiodic are not very clearly manifested, 
and its tonic action is too slow in a class of cases in which prompt 
support to the system and immediate stimulation are often so 
urgently called for. But, as well observed by Dr. Aitken, "Testi- 
mony of the most undoubted kind has been addueed of the pro- 
phylactic influence of hark or quinine during service in unhealthy 
countries ; and nowhere more unequivocally than on the West 
Coast of Africa, by Drs. Bryson and Baillie." As a prophylactic, 
quinine may be administered in from three to ten grain doses 
once or twice daily. Wine constitutes a good vehicle for its 
exhibition ; and its use should be continued for two or three 
weeks, according to circumstances. 

The perchloride of iron is employed as an internal remedy in 
doses of from three to six grains, two, three, four, or more times 
in the day, and in some cases at least with apparently good 
results in arresting the hemorrhagic tendency. Chromic acid, in 
doses of from three to six grains, may also be used internally 
with the same view; but, in my opinion, it has not proved so 
effective a remedy as the perchloride of iron. 



USE OF STYPTICS, OPIATES, ETC. 291 

An abortive plan of treatment is much in vogue with some 
practitioners, the object being to cut short the disease if possible. 
With this intent twenty grains of calomel are administered at 
once, with twenty-four grains of quinine. This is followed by 
two drachms of carbonate of magnesia with two ounces of sul- 
phate of magnesia, in eight ounces of peppermint water. (Dr. 
Blair.) These doses are repeated at intervals of from four to six 
hours: one dose is said generally to be sufficient; but four doses 
have been administered before the desired result was produced, 
and without the induction of cinchonism. " When a state of 
apyrexia is induced, the end is attained; but if the urine has 
become coagulable, or the epithelium of the tongue has begun to 
be shed, it is of no use pushing the 'aborting doses' further." 
(Aitken, Blair.) I have myself no experience of this plan of 
treatment ; but I consider it as one not free from danger, unless 
in cautious hands. Dr. Copland and others speak highly of the 
use of turpentine in drachm doses by the mouth, or half-ounce 
doses in the form of injection per anum. From the well-known 
styptic properties of this drug its use is rationally indicated, and 
it comes under the same category as perchloride of iron. 

Dr. Blair recommends the use of powdered gum arabic (three 
drachms to six ounces of cold water, in tablespoon doses every 
two hours, or oftener) when the epithelium of the tongue is 
abraded. Cold affusion is spoken of by Bancroft, with a view to 
alleviate the sense of burning heat so often urgently complained 
of. Iced drinks may be given with a like intent. The wet sheet 
is lauded by others, and as a means of supplying moisture to the 
system when the stomach has ceased to be an absorbing viscus. 
Some authors seem to recognize a supplementary action in the 
skin, by which it absorbs water, and thus aids in reducing the 
crasis of the blood. 

Morphine, creasote, and hydrocyanic acid may be used to allay 
the nervous excitement and the irritation of the stomach. The 
first of these drugs must be given with caution, as yellow fever 
seems to exercise some predisposition on the system whereby it 
is rendered more sensitive to narcotics. When the urine is not 
albuminous morphia is said to be better borne. Dr. Blair con- 
siders one-fourth of a grain of the acetate of morphia a maximum 
dose in the twenty-four hours for an adult. 

Mild and bland food must be carefully administered to support 



292 YELLOW FEVER. 

the patient's strength, and stimulants with a liberal but judicious 
hand. Effervescing wines are often grateful and refreshing to the 
patient. 

The following valuable conclusions are given by Dr. J. R. 
Martin : " The most speedy means of prevention, in respect to 
towns and garrisons, will always be found in the removal of both 
the sick and the healthy to a locality where the temperature is 
sufficiently low, such as a neighboring elevated range, or dry 
well-ventilated ground; the next most ready means is segre- 
gation. 

"Whenever fever makes its appearance on board ship, she 
should at once proceed to sea, and into the coolest atmosphere 
within reach. 

u The most immediate measures of prevention should be to 
obviate direct solar exposure, to prevent fatigue, and excesses in 
the use of spirituous and fermented liquors. 

" Seamen should be kept as remote from unhealthy coasts as is 
consistent with duty, anchoring some miles out to sea, during the 
night especially. 

"Duty in boats should be conducted during the mornings and 
evenings, avoiding alike the noon-day heats and the deadly ema- 
nations from the shores common to the night. When men are 
landed, a carefully selected encampment should be chosen on 
high and dry ground. 

" Meals should be regularly served and carefully cooked, and 
no more spirit ration should be issued than is customary. Coffee 
should be given early in the morning as a habit, and after unusual 
fatigue, cold, wet, or mental depression ; and labor ought not to 
commence until coffee has been taken. 

" Holds of ships should not be cleansed on the spot where the 
fever has originated, or during its prevalence, but should be 
deferred till the arrival of the vessel in a cold latitude. 

"Green wood should not be placed on board ship in hot cli- 
mates ; it ought to be ' barked' and partly charred." 

With respect to quarantine regulations, this is hardly the place 
to enter on the subject ; but I may briefly state my own convic- 
tion that, as ordinarily carried out, they are of little or no effect 
in preventing the spread of the disease. 



EXTERNAL APPEARANCES OF BODY. 293 



CHAPTER X 

(SUPPLEMENTARY.) 



PATHOLOGICAL ANATOMY OF THE YELLOW FEVER OF LISBON (1857). 

I shall here consider in anatomical order the various lesions 
observed in fatal cases of yellow fever during the epidemic at 
Lisbon. It may be useful to give them in extenso, in this place, 
as full records of the pathological anatomy of the disease are not 
readily available. 

EXTERNAL APPEARANCES. 

Generally speaking, the body was well nourished, the muscular 
structures were well developed, and there was commonly more 
or less abundant deposit of adipose tissue, which gave full and 
rounded proportions to the trunk and extremities. Instances of 
remarkable obesity were by no means uncommon, more especially 
in females, in whom it was sometimes extreme. I think the case 
No. 12, Table II. p. 53, Parliamentary Report, was the most ex- 
aggerated example of superficial, interstital, and internal adipose 
accumulation that I have ever examined. The masses of fat 
deposited between the layers of abdominal muscles, for instance, 
and in the mesentery, and on the posterior wall of the abdomen 
were several inches (2 or 3 inches) in thickness, and far surpassed 
anything of a similar kind I have ever witnessed. 

Examples of an opposite condition, or that of emaciation, 
wasting, and ill-nourished frame, were very rare indeed, and I 
can call to mind but a very few instances of anything like con- 
siderable wasting of the tissues. 

It is to be remembered that the mean age of those attacked 



294 PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

with yellow fever was about 33 for both males and females. 
This represents the prime of life, of vigor, and of physical de- 
velopment of the various organs, parts, and tissues. It was 
therefore with the bodies of persons struck down in the prime 
of life, and by a disease that causes no wasting or emaciation, 
for its course is too rapid, that we had to deal in the post-mortem 
room. 

Other corroborative observations are not wanting, to warrant 
the statement that the Portuguese race is well developed and well 
nourished. 

Kigor mortis was well developed and persistent in the great 
majority of cases. The muscular masses were thrown promi- 
nently into relief on various parts of the trunk and extremities. 
The trapezius, deltoid, pectorals, biceps, and the flexors and 
extensors of the forearm and hand were thrown up in rigid 
elevations. The hands were in the majority of instances firmly 
closed. 

The recti, vasti, and gastrocnemii in the lower extremities were 
boldly defined, and could be traced through a large part of their 
extent and attachments. The numerous muscular markings 
about the knee were well defined. The contraction of the mus- 
cles was persistent and uniform. Cadaveric movements have not 
been observed to occur as far as I am aware. I have not myself 
witnessed, nor have I heard mention, of any such movements. 
Irritability of the muscular fibres usually remained at the period 
of post-mortem examination (average 10 to 12 hours P. M.) to a 
considerable extent. A cross section made into the recti or vasti 
muscles in the thigh was followed by retraction of the opposed 
surfaces to the extent of 1 or 2 inches. Similar retractions were 
observable in sections of almost all the other muscles. 

The feet were contracted and turned in: the heel was raised 
by the tendo-Achillis : the dorsum of the foot was arched by the 
plantar muscles, while the outer edge inclined inwards, and the 
plantar surfaces looked towards each other. 

The post-mortem examinations were made in the spacious, cool, 
and well- ventilated " Salle des Dissections" of the Medico-Chirur- 
gical School of Lisbon, attached to the great hospital of St. Jose. 
The temperature of this room was seldom above 50° to 55° 
Fahrenheit. The examinations were made at various intervals 
after death ; sometimes after the lapse of only a few hours (3 to 4 



EXTERNAL APPEARANCES OF BODY. 295 

hours); at other times 12 to 16 hours had elapsed. An average 
of 10 hours may be stated as the time after death at which the 
most of my investigations were made. 

There was nothing in the conditions to which the bodies were 
exposed after death, and before post-mortem examination, to 
promote an unusually early decomposition, and except in the 
instances to be subsequently specified, no instance of remarkably 
advanced decomposition was observed. 

Generally speaking, the cooling of the surfaces and of the 
internal parts took place gradually, and without any remarkable 
difference from the ordinary process of lowering of the tempera- 
ture of dead bodies. I have seen no instance of elevation of 
temperature post mortem, in the algid cases, nor am I aware that 
any such elevation has been determined. It is quite possible, 
however; and in such cases as those already cited, with the 
thermometer in the axilla at 96° Fahrenheit during life, and pro- 
bably far lower in the extremities, which were sensibly cold to 
the touch, it is even likely that for a short period after death 
some increase of temperature would have been observed. I shall 
presently allude to some remarkable cases of continued warmth 
of the body for 16 hours and upwards after death. 

General Appearance and Coloration of the Surface. — The yellow 
fever cases assumed a peculiar cachet, and a special physiognomy 
of a very marked character, which once seized is never forgotten, 
though like many other striking phenomena, by no means readily 
admitting of being well conveyed in words. Indeed the physi- 
ognomy of the cases after death was nearly as characteristic as 
that presented during life. It wanted certainly that marked and 
striking feature of anxiety and apprehension, anxiete epigastrique, 
already alluded to. This was often replaced in the dead subject 
by a calm, placid, and even pleasing expression of certain features, 
contrasting ill with the appearance of bloody exudation and 
hemorrhagic straining on other parts. 

The surface was generally, I may say invariably, colored of a 
more or less deep or light yellowish tint, in some part of its 
extent more or less limited, as the case might be. I believe that I 
have not witnessed a single instance of the total absence of yellow 
coloration post mortem from all and every part of the surface, 
in any case entitled to be considered as an example of true yellow 
fever. 



296 PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

The yellow coloration was observed in the conjunctivas (inva- 
riably) ; on the parts naturally the fairest and whitest ; the 
cheeks, neck, breast, abdomen, anterior surface of the arms and 
thighs. In some rare instances the yellow coloration seemed 
general over the whole surface, anteriorly and posteriorly, on the 
hands and on the feet. 

The tint varied a good deal ; it was sometimes a light, faint, 
sometimes a rich canary or gamboge color, sometimes of a deeper 
yellow with a more dusky hue, and less transparency of both 
color and integuments. Sometimes it approached to a tawny 
yellow. Not infrequently the effect of the yellow color was 
modified a good deal by the intermixture of minute cutaneous 
capillarity, which gave a kind of mottled effect from the results 
of admixture of yellow surface with minute reddish or purplish 
spots. 

Most commonly the posterior parts of the neck, trunk, and 
extremities, presented more or less of livid bluish red or purplish 
discoloration. This was often observable in the more exposed 
parts of the hairy scalp, at the border of the forehead, at the 
angles of the jaws, and in the line of the whiskers. It some- 
times advanced even upon the malar bones. On the lower third 
of the forearm, the wrist, and the entire hand and fingers, the 
coloration was usually of a more or less livid bluish tint. It was 
commonly the same on the lower third of the leg, sometimes from 
the knee down, on the ankle and on the foot. In extreme cases 
the hands and feet were dusky, purplish or bluish red, blue pre- 
dominating. 

Purpuric spots thickly scattered over the surface were com- 
monly observable in that class of cases already described under 
the term algid. They were unaltered after death ; their size was 
generally from a line to one or two lines in diameter. Some- 
what larger patches — purpuric patches — were occasionally ob- 
servable. 

A very remarkable feature in a physiological as well as a 
pathological point of view, was the size of the penis and testicles, 
in a very great many of the cases, I would say the majority of 
them, observed by me in the post-mortem rooms. It was not un- 
common to find the penis from three to four inches in length, and 
sometimes eveu more, and thick in proportion. The testicles were 



EXTERNAL APPEARANCES OF BODY. 297 

of corresponding dimensions, the sac of the scrotum large and lax, 
and the testicles hung low down. 

These organs were constantly the seat of intense dark livid 
congestion; the dorsal veins of the penis and the superficial 
scrotal veins being much distended. There was apparently in 
many instances a special determination of congestive action to- 
wards the genitals. 

I am informed (on medical authority) that a very enlarged state 
of the genitals is by no means an uncommon physiological con- 
dition amongst the population in question. This is a very inte- 
resting point, by no means sufficiently well worked out as yet, but 
undoubtedly having some relation to natural or acquired physical 
characteristics of race. 

I have no observations of a similar kind as to the state of 
corresponding parts in females. I am not aware that any such 
observations have been made by others. 

Yellow coloration sometimes appeared for the first time after 
death in the algid cases. We have already, in the clinical history 
of these cases, remarked on the general absence of yellow colora- 
tion during life. In some instances the yellowness was slightly 
apparent a few hours before death ; in others, and the great 
majority of instances, it was not evident while life continued, but 
soon after death it began to appear in the conjunctivae, and gradu- 
ally spread to the surface. 

The yellow color did not obliterate the peculiar physiognomy 
of the algid cases, which was still recognizable after death. The 
lips, nose, posterior parts of the trunk, the hands and feet, and 
often the forearms and legs, retained the characteristic semi- 
cyanotic condition, besides which, the purpuric spots were every- 
where observable. These phenomena combined gave a character 
to the algid cases recognizable after death almost as readily as 
during life. 

Several states of the cutaneous surface were met with, both as 
to variety and intensity of coloration. Amongst the most re- 
markable was that observed in connection with some examples 
of the hemorrhagic form. It may be denominated hemorrhagic 
staining or bloody imbibition of the cutis. The color was diffused 
in a uniform deep bloody purplish-red tint through large surfaces 
of the integument. It was not merely subcutaneous extravasation, 
but an actual coloration and staining of the cutis, from imbibition 



298 PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

of the coloring matter of the blood. It occupied in one remark- 
able instance (Case 13, Table I. p. 44, Parliamentary Eeport), the 
cheeks, neck, shoulders, and upper part of the chest, in one con- 
tinuous surface of color. It has been nearly as extensive in other 
cases. It completely obliterated all other coloration in the parts 
affected, replacing the yellow color when that had existed during 
life, as was the case in several instances. This hemorrhagic stain- 
ing was entirely different from the livid appearance of dependent 
parts, and equally so from the semi-cyanotic state of the surface 
found in the algid cases. It was obviously the result of extensive 
subcutaneous hemorrhage, with extravasation of blood in an 
excessively thin and uniform stratum. 

Hemorrhagic exudation of a more distinct kind has been ob- 
served, post mortem, from abraded and excoriated surfaces and 
from the surfaces of vesicated parts. It has been observed from 
excoriations about the axillae and groins (case of extremely obese 
female, No. 12, Table II. p. 53, Parliamentary Eeport); not in- 
frequently from excoriations about the labia pudendi. Vesicated 
surfaces on the nucha, epigastrium, thighs, calves of the legs, 
dorsum of the feet, and other parts have been found stained with 
hemorrhagic exudations. Gangrenous erysipelas of the legs has 
been found in some instances, as the result of the low state of 
the system, or more probably, of the long continued action of 
vesicating applications, such as blisters, mustard poultices, &c. 
Such means were used as popular remedies before the patient's 
admission to hospital, and from the temporary want of power in 
the system, especially in the algid cases, they produced little or 
no effect till reaction was somewhat established, when intense 
inflammatory processes were set up, followed in some instances 
by gangrenous destruction of the tissues. 

Signs of recent hemorrhage were commonly observable about 
the nose and mouth, with bloody sordes on the teeth and gums. 
There was not unfrequently an escape of some considerable 
quantity of blood from the nose, the mouth, or even the stomach 
after death. The lower parts of the face were commonly smeared 
and stained with dark blood, and the objects in immediate con- 
tact with the body were similarly stained. Hemorrhagic stains 
have likewise been observable about the eyelids and meatus of 
the ears, also from some other situations which gave exit to blood, 
as it were, accidentally. 



EXTERNAL APPEARANCES OF BODY. 299 

In the class of cases last alluded to 3 and in some extremely 
rare instances of advanced decomposition, the superficial vessels 
were prominent and distinctly observable on the surface. The 
small veins of the forehead and temples, the superficial jugulars, 
and some of the smaller veins of the neck were brought into 
view. In the instances of rapid decomposition, to be presently 
noticed, dark-colored arborescent veins were observable on various 
parts of the surface, neck, chest, arms, abdomen, and thighs. 
This peculiar dark color, resulting from decomposed blood, and 
which contrasts with that of the usual blue venous tint of dis- 
tended superficial veins, is very characteristic; and in the in- 
stances now in question, caused me readily to recognize the 
condition as similar to what I had already seen and described in 
connection with acute gangrenous processes. 1 

Evidences of Decomposition. — Evidences of advancing decompo- 
sition were, however, generally speaking, very rare at the period 
at which our examinations were made (average, 10 to 12 hours 
after death). Even the usual greenish coloration of the abdomi- 
nal walls was not remarkably evident, and in many instances was 
certainly altogether absent. This would be more remarkable 
but for the absence of similar coloration in a great many instances, 
at least, in the parts within the abdominal cavity usually so dis- 
colored by escape of biliary coloring matter from the gall-bladder, 
viz., the under surface of the liver, the hepatic flexure of the 
colon, the contiguous parts of the peritoneum, &c. 

Softening and detachment of the cuticle were observed only 
in the remarkable instances of acute decomposition already 
alluded to. See Case 19, Table II. p. 55, Parliamentary Eeport. 
The body was still warm everywhere 16 hours after death. The 
surface of the thorax, abdomen, neck, and parts of the arms and 
face, were covered with prominent very dark purplish veins. 
The least pressure on any part of the surface was sufficient to 
detach the cuticle in large sheets, leaving a discolored, dark, dirty 
reddish surface beneath. A corresponding amount of advanced 
decomposition was found in the several organs, in the thorax and 
abdomen. 

State of Superficial Parts on Section. — The subcutaneous areolar 

1 See Parliamentary Report (Blue Book) to the Minister-at-War on the Patho- 
logy of the Diseases of the Army in the East. 



300 PATHOLOGICAL ANATOMY OF YELLOW FEVEE. 

tissue, the muscles and connecting tissues were sometimes found 
engorged. Slight diffuse hemorrhagic exudations were observed 
through the subcutaneous tissues. Limited patches of ecchymosis 
were likewise presented here and there. This escape of blood 
by extravasation into the superficial parts and tissues was confined 
to the class of cases I have denominated hemorrhagic. Taking the 
cases as a whole, I am inclined to regard it as by no means a 
common kind of hemorrhage: it was certainly by no means so 
frequent as any other of the various forms of extravasation of 
blood. Vascular repletion without actual extravasation was more 
usually observed. This was evident in the integuments, in the 
subcutaneous tissues, and very commonly in the muscular struc- 
ture, which was dark-colored and congested in appearance. 

The several parts both internal and external were generally 
found to have preserved their natural moisture. 

CRANIAL CAVITY. 

Dura Mater. — Yellow coloration was not infrequently observ- 
able in the dura mater. It was chiefly on the outer surface that 
this coloration was remarked. Arborescent injection with punc- 
tiform blood spots was occasionally found, but never, in my 
examinations at least, to any very remarkable extent. 

The sinuses of the dura mater were sometimes found engorged. 
This was especially observable in the great longitudinal and the 
lateral sinuses. It was far from a constant or even general 
condition, and existed only in a minority of the cases. Kemark- 
able engorgement of the vertebral veins was found in some one 
or two instances. 

Arachnoid. — The cavity of the arachnoid pretty frequently 
presented some slight increase in the quantity of serum effused. 
The membrane itself was in general transparent and free from 
alteration, but it has been found opalescent and occasionally 
smeared with blood. In no instance that I am aware of has any 
lymphy exudation been found upon the arachnoid surfaces. 

The serous effusion has varied from a couple of drachms to as 
many ounces. It has been found clear, pale, devoid of any appre- 
ciable coloration, yellow or otherwise, and also in other (rare) 
instances more or less tinged with blood. I have not found it 
distinctly yellow in more than two or three instances. The 



PIA MATER. — CEREBRUM. 301 

subarachnoid spaces have not infrequently been found filled with 
clear serum, with gelatinous and opalescent serosity more rarely, 
and in some few instances only with extravasated blood. 

Pia Mater. — General congestion of the surface of the hemi- 
spheres to a slight extent has not been uncommon. Marked 
vascular injection has usually been only partial, being confined 
to one hemisphere, or more commonly to a part only of the sur- 
face of either the right or left. Bloody effusion on the surface of 
the hemispheres has been occasionally observed. It was generally 
confined to a small surface, but has sometimes been found in more 
than one situation upon the same hemisphere. The posterior 
parts of both hemispheres were sometimes congested, probably 
from hypostatic determination of blood. 

In some examples of the hemorrhagic form, we have found the 
subarachnoid spaces filled with effused blood, much bloody serum 
in the arachnoid cavity, and the surface of both hemispheres and 
of the cerebellum deeply congested. This, however, has been a 
comparatively rare condition. 

Cerebrum. — The cerebral substance on section presented very 
generally a slight amount of vascular spotting, constituting what, 
to avoid periphrasis, we have designated with the French patho- 
logists, the sable' condition. Excessive development of this con- 
dition of increased vascularity of the cerebral substance has been 
witnessed only in cases of the hemorrhagic form. I have in no 
one instance found actual hemorrhage into any portion of the 
cerebral substance. 

The cerebral substance has been noted in some one or two 
instances as slightly dry. Appreciable changes in consistence 
either as to hardness or softness were extremely uncommon, if 
they existed at all. I have no observation of any such changes 
beyond that just mentioned. 

The ventricles contained variable amounts of serum ; sometimes 
but a drachm of clear transparent fluid. In rarer instances the 
lateral ventricles were filled with serum, and in some few cases 
bloody serum was found in them. The choroid plexuses were 
sometimes found congested ; most commonly there was no appa- 
rent alteration in them. It is noted in one instance that the 
velum interpositum was congested ; but no other observation 
confirmed the idea of this being an important or usual change. 

Cerebellum. — General superficial congestion was not uncommon, 



302 PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

but no marked state of vascular injection was observed, except 
in the hemorrhagic cases already noticed. 

Spinal Cord and Membranes. — The spinal canal was not gene- 
rally examined, a few complete autopsies having satisfied us that 
there were usually but unimportant pathological changes to be 
met with in this situation. 

Spinal Membranes. — Slight general congestion of the mem- 
branes has been observed, but to an unimportant extent, except 
in cases of the hemorrhagic form. In these latter intense en- 
gorgement of the vertebral sinuses and veins has been found, 
with marked congestion of the membranes. Distinct hemorrha- 
gic effusions I have not observed. 

Substance of the Cord. — A slightly sable condition of the cord 
has been observed on horizontal sections being made in the 
hemorrhagic form. I have not noted any varieties as to consist- 
ence in the nervous substance of the cord. 

Well-marked yellow coloration has not been found in the brain, 
spinal cord, or in the membranes, except in the cases already 
specified of yellowness of the dura mater. 

It will be seen from these anatomical details that the cranial 
and vertebral canals, and the great nervous centres, participated 
only in a secondary degree in the general hemorrhagic lesion. 
Even when profuse in almost all other situations, it was but 
moderate in amount and extent in the cerebral and spinal cavities, 
or on the surface of the brain and spinal cord. For the best 
example of hemorrhagic lesion of the cord and its membranes, 
see especially Case 6, Table IT. p. 51, Parliamentary Eeport. 

We certainly cannot connect in any way the leading clinical 
features of the disease with anatomico-pathological states of the 
nervous centres and their appendages. 

It may be safely stated that there has been an entire absence 
of evidence of inflammatory lesion in the brain and cord, and 
their membranes. The congestion present cannot be taken in 
proof of the existence of any such lesion. This condition (vas- 
cular injection) was, when best marked, always that of congestive 
engorgement rather than of active hyperemia. In the cerebral 
substance itself and in that of the cord, there was a complete 
and invariable absence of any alteration of color, of consistence, 
or of any other physical condition which could lead to the sup- 
position that it was the result of inflammatory action. 



THORACIC CAVITY. 303 

The symptoms of cerebral excitement during life, when pre- 
sent, and they were far from constant, were, as already fully 
considered, not those of inflammatory lesions. There was like- 
wise a want of correspondence and uniformity of result between 
the symptoms of cerebral excitement observed during life and 
the states of the brain and its membranes found post mortem. 

THORACIC CAVITY. 

Lungs — Parenchyma. — With but few exceptions congestion of 
the pulmonic substance was observable in one or both lungs, on 
the anterior or on the posterior aspect, and in a quantity varying 
from that of a siDgle limited space in one lobe to the complete 
hemorrhagic engorgement of the entire pulmonary parenchyma 
in both organs. 

The ordinary hypostatic congestion no doubt formed the basis 
of the condition in many instances, and was probably in some 
the only state present. General engorgement of the anterior 
parts was, however, very often observable. In many cases the 
lungs collapsed but little; when the thorax was opened the fingers 
broke through the pulmonic substance readily, giving exit to a 
quantity of blackish blood mixed with air. This was the most 
common condition, but yet it was not infrequent to find well 
marked patches of distinct apoplectic engorgement of limited 
parts of lobes, which felt firm to the finger, and when broken 
through gave exit to clots of blood, in masses of various sizes. 
In Cases 8, see Table II. p. 52, Parliamentary Eeport, the right 
lung presented numerous distinct apoplectic patches, while in the 
left there was more diffuse pulmonary hemorrhage. 

A congested semi-pneumonic solidification of the anterior part 
of the right lung was noticed in Case 12, see Table II. p. 58, Par- 
liamentary Eeport ; but even this amount of inflammatory lesion 
was very rare. True pneumonic consolidation I have not wit- 
nessed in a single instance. 

Bronchial Membrane. — Congestion of the bronchial membrane 
was generally observable, it was commonly of the passive kind, 
quite distinct from any true hyperasmic state; no such condition 
as that of active hyperemia with inflammatory redness was de- 
termined in any single instance. There was no observable in- 
crease in the bronchial secretion. 



304 PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

Pleurce. — Old adhesions of the pleurae were observed in some 
cases: in one or two instances there was complete adhesion of the 
lungs to the parietes throughout. I have not observed any- 
pathological condition of recent origin in the pleural membrane 
in any of the cases examined by me. 

Advanced decomposition of the pulmonic substance was ob- 
served in Case 19, Table II. p. 55, Parliamentary Eeport. The 
pulmonary structure had lost its consistence, and broke down 
readily on the slightest pressure or traction, so that it would have 
been impossible to remove either organ from the chest without 
almost completely breaking up its substance. 

Heart. — The pericardium in some few instances contained effu- 
sions of serum; it was variable in amount from a few drachms to 
a couple of ounces. The serum effused was in one or two cases 
yellow or straw-colored. Bloody serum to the extent of one, two, 
three, or more ounces was found in the pericardium in a few cases. 
In one or two instances purpuric (hemorrhagic) spots were ob- 
served on the parietal layer of the pericardium. 

Surface of the Heart. — Distinct purpuric spotting of the surface 
of the heart has been observed in some instances. The spots 
were of a dark purplish tint, varying from one to two or three 
lines in diameter ; in one or two instances only were patches of a 
somewhat larger size observed; in one instance the posterior part 
of the apex of the left ventricle presented a purpuric patch from 
J to J inch in diameter. 

These spots were sometimes associated with spots on the endo- 
cardium and on the parietal layer of the pericardium. Their 
usual situation was on the anterior aspect of the right ven- 
tricle, but. they have been found on the auricles and on the left 
ventricle. 

Purpuric spots have been observed on the endocardium, in the 
auricles and ventricles, most commonly and in most abundance 
in the right auricle ; in one instance a large ecchymotic patch, 
\ to J inch in diameter, occupied the auricular wall in the neigh- 
borhood of the foramen ovale. 

Purpuric spots in the heart were usually associated with similar 
spots on other internal parts, but by no means necessarily with 
the same peculiar condition externally. There was an entire 
absence of the algid condition or of purpuric spots on the skin 
in Case 5, Table II. p. 51, Parliamentary Eeport, which presented 



STATE OF THE BLOOD. 305 

well-marked purpuric spotting on the endocardium and pericar- 
dium, in the oesophagus, and on the liver and kidneys. 

Fatty deposit on the surface of the organ was occasionally 
observable; I think it was most thick in the cases of very obese 
females. Interstitial fatty deposit and true fatty degeneration of 
the muscular fibres I have not met with. 

It may be a question whether, in the case of acute decomposi- 
tion so frequently alluded to, fatty degeneration of the heart was 
present or not. The amount of decomposition and disintegration 
of the muscular fibre was such as to preclude the possibility of 
this being accurately determined. We are aware of the connec- 
tion between fatty states of the heart and the rapid and early 
occurrence of decomposition, so well illustrated by the labors of 
the Dublin pathologists; but in the case in question the decom- 
position and disintegrative histolysis of the tissues were in a more 
advanced state than I have ever witnessed, except in connection 
with the forms of acute and general constitutional gangrene 
observed and described by myself in my official "Keport on the 
Pathology of the Diseases of the Army in the East." 

The muscular structure of the heart has been frequently found 
of a deep dark red color. This was most marked and exaggerated 
in the hemorrhagic cases, in which the muscular fibre had the 
appearance of having been steeped in dark venous blood. 

A yellowness of the fibre was occasionally, but not commonly, 
presented. Perhaps most frequently there was no appreciable 
departure from the normal condition, either as to color or con- 
sistence. 

Endocardium.' — The endocardium has been found stained of a 
yellowish color rarely : more frequently, in the hemorrhagic form, 
it was of a dark purplish tint, as if stained from imbibition of 
dark venous blood. Both kinds of coloration usually extended 
to the valves, both the auriculo-ventricular and the semilunar. 
It was commonly, when present, equally well seen on both sides 
of the organ. 

The occurrence of purpuric spots on the endocardial surface 
has already been sufficiently noticed. 

Valvular lesions were of the utmost rarity. In one instance 
only was there a well-marked instance of organic disease of the 
valves. It was an example of permanent patency of the semi- 
lunar valves of the aorta. It is needless to say that the condition 
20 



806 PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

was of old standing, and in no way connected with the special 
disease of which the patient died. 

There was a constant and complete absence of inflammatory 
lesion of any kind in the heart or its membranes. 

Blood in the Cavities of the Heart. — There was great variety as 
to the amount and character of the blood in the heart's chambers 
after death. 

Both ventricles have been found entirely devoid of blood. 
This was a comparatively rare condition. A moderate amount 
of dark, thick, but fluid blood, with or without small black clots 
interspersed, but without fibrinous coagula, was the condition 
most frequently found. The right ventricle more commonly 
contained blood than the left. In a few rare instances all the 
chambers of the heart were found gorged with semi-fluid black 
blood. Occasionally long yellow fibrinous coagula were observed, 
usually in the right ventricle, more rarely in the left. 

The blood which escaped from the great vessels on section of 
them, was generally intensely black, semi-fluid, and mixed with 
black clots. 

ABDOMINAL CAVITY. 

State of the Peritoneum, — No appreciable departure from the 
normal condition was observable in the serous membrane lining 
this cavity. I have not observed hemorrhagic effusion qr pur- 
puric spots upon this serous surface: effusion of serum was like- 
wise of very rare occurrence. 

I have already alluded to the presence of enormous masses of 
fat in the mesentery and on the loins in obese females. 

The general external aspect of the intestinal surface was very 
variable indeed. The whole intestinal canal has in some instances 
presented a uniform livid purplish tint on the peritoneal surface. 
This coloration did or did not correspond to hemorrhagic effusion 
within the tube ; there was no constant or necessary connection 
between the two states of external congestion and hemorrhagic 
effusion within. The mesentery was sometimes deeply congested. 
Some of the examples of most profuse intestinal hemorrhage 
occurred in cases in which the peritoneal surface of the intestines 
presented the ordinary coloration, or again, when the color was 
of an entirely yellowish tint. See Cases 2 and 22, Table II. 



STATE OF STOMACH. 307 

pp. 49 and 56, Parliamentary Eeport, for illustrations of these 
conditions. There was a very constant absence of the usual 
greenish biliary discoloration of the hepatic flexure of the colon 
and contiguous parts. 

(Esophagus. — The mucous membrane of the oesophagus wa3 
occasionally, but not by any means very constantly found con- 
gested. In one or two instances it presented several purpuric 
spots, similar spots being observable in the stomach, heart, liver, 
and kidneys. 

The fringe of epithelium at the cardiac orifice was found 
occasionally in a state, as it were, of abrasion, the epithelial scales 
being detached. Whether this state and appearance were in any 
way connected with or caused by the repeated efforts at vomiting 
I cannot say. 

Stomach. — This organ has been found distended, contracted, 
and occasionally presenting the hour-glass constriction: its most 
usual state was that of moderate contraction ; its mucous surface 
was consequently slightly corrugated and convoluted in the ma- 
jority of cases. 

Its contents varied much ; they were sometimes natural, some- 
times hemorrhagic. In somewhat more than a third of the cases 
the stomach contained semi -fluid blackish matter in greater or 
less abundance. This matter was sometimes identical in cha- 
racter with the black vomit presented during life, being dark 
brown, noir de caffe, mostly fluid but containing fine dark-brown 
or blackish particles in suspension. At other times the contents 
of the stomach seemed almost pure and unaltered blood, of very 
dark red color, partly mixed with clots, or of a thick homogene- 
ous consistence in other instances. Of the nature of this fluid no 
doubt could exist; it presented under the microscope blood-cor- 
puscles variously altered but readily recognizable as such. 

The mucous surface was, in a few instances, normal; its condi- 
tion was very various, but it commonly presented some one or 
other of the following appearances: — 

(a) A state of more or less extensive dark congestion was 
most frequently observable; when partial, the congestion was 
usually presented in the great curvature or bas fond of the 
organ. 

(b) Scattered patches of congestion irregularly distributed were 
likewise of sufficiently frequent occurrence, the intermediate parts 



808 PATHOLOGICAL ANATOMY OF YELLOW FEVEK. 

presenting a truly normal state. Large arborescent vascularity 
was sometimes, but not very commonly, found. 

(c) In other instances a general dark punctiform congestion was 
present through the greater part of the gastric surface; minute 
points of stellate vascularity, pretty thickly distributed here and 
there, formed another variety of congestion, and were observable 
in many cases. 

(d) Occasional patches of ecchymosis were sometimes found. 
Most of these states, even to deep general dark congestion, were 
observable in cases in which no blood or hemorrhagic effusion of 
any kind was found in the stomach. 

(e) In one instance a general rose-colored congestion of the 
gastric surface was presented. The stomach contained much 
black blood. 

(/) In the cases attended with hemorrhagic effusion into the 
stomach, the gastric surface was usually stained of a deep purplish 
tint. This color, I make no doubt, was in greater part owing to 
hemorrhagic staining or imbibition of the coloring matter of the 
blood ; intense vascularity of the mucous surface was observable 
on minute inspection, even with the naked eye, still better with 
a pocket lens of moderate magnifying power. But the most 
striking and predominant appearance was that due to the general 
purplish tint; the hue was, in some instances, very deep, approach- 
ing to bluish black. 

(g) In some instances purpuric spots were observable here and 
there on the gastric surface, the intermediate parts being normal 
or presenting only slight general punctiform or stellate vascu- 
larity. 

(h) The mucous surface was generally in good preservation, 
the epithelium firm, persistent, and not detached or softened. 
Signs of decomposition of the gastric surface were generally 
absent, and the epithelial layer could be brought away with the 
knife, perfect in distinct flakes, and not as a softened debris. 

(i) Post-mortem digestion and consequent erosion of the gastric 
epithelium was observable only in a very few cases. A remark- 
able prominence and filling of the lenticular glands was presented 
in one or two instances. 

I have not observed any condition that would warrant the 
supposition that active hypersemia of the gastric membrane was 
present. I regard the state of injection so commonly observable 



STATE OF SMALL INTESTINES. 809 

in the stomach as part of the general vascular lesion which caused 
such a tendency to hemorrhagic action upon the entire mucous 
surface. In no instance have I found any evidence of ulcerative 
action. 

I have not detected any one instance of ruptured vessels on 
the gastric membrane. The hemorrhagic action must have been 
confined to vessels approaching the capillary condition, if it did 
not take place directly and exclusively from ruptured capillaries. 

Duodenum. — States very similar to those presented by the 
stomach were found in the duodenum, both as to the contents 
and the characters of the mucous surface of the organ. Hemor- 
rhagic purpuric spots have been observed upon its mucous sur- 
face in the cases already alluded to, presenting this condition in 
the oesophagus, stomach, heart, liver, and kidneys. 

Jejunum and Ileum. — They were most commonly in a condition 
of moderate distension. The mucous surface in these portions of 
the intestines presented various states of congestion. Sometimes 
minute arborescent vascularity was found over large tracts of 
surface. In other instances minutely dotted injections were ob- 
servable. In the hemorrhagic cases uniform dark purplish colora- 
tion existed throughout. In one or two instances a uniform 
bright pink coloration was observable in the ileum, while profuse 
hemorrhagic effusion had taken place into its cavity. 

The contents of these parts of the intestine have been various : 
in a few instances bilious-colored fecal matter was observable. 
Dark greenish matter was found in other cases. Biliary-colored 
matter has been found in the upper portion of the intestines, 
while blackish hemorrhagic effusion existed in the lower parts in 
the same case. The converse of this has also been presented, 
black hemorrhagic effusion into the stomach and duodenum, 
while natural-colored fecal matter (with biliary coloring) has 
been present throughout the remaining parts of the intestinal 
tract. 

In more than one-third of the cases extensive hemorrhagic 
effusion was present throughout the greater part of the jejunum 
and ileum, and it frequently extended to the colon. 

This effusion varied much in appearance ; it was a black inky 
fluid in some cases, in others of a blackish red, and of more 
bloody appearance. It was sometimes partly homogeneous, in 
other cases only semi-fluid ; in others, again, slimy, thick, and 



310 PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

mixed with the debris of mucous epithelium. It was sometimes, 
likewise, mixed up with fecal matter, and variously altered in 
appearance and consistence. The quantity was very considerable, 
in some cases filling the whole tract of the jejunum, ileum, and 
upper part of colon, while a similar fluid was found in the stomach 
and duodenum. Such cases might be considered as terminating 
in one vast mucous hemorrhage. Microscopically examined the 
nature of the fluid, however altered in appearance, was placed 
beyond doubt by the presence of blood-corpuscles. Epithelial 
scales, nuclei, and an ill-defined debris were likewise observed in 
abundance ; but though the utmost care was employed in micro- 
scopic examination, no detached particles of mucous membrane, 
capillary vessels, or other constituent part of the mucous surface, 
other than the epithelial elements just mentioned, could be de- 
tected. 

We may here notice the characters presented by the black 
vomit, and the similar blackish and otherwise colored fluid or 
semi-fluid matter found in the stomach and intestines post-mor- 
tem, or which had been ejected, by either the mouth or anus, 
during life. Numerous specimens of black vomit were carefully 
examined by the microscope, and with various chemical reagents. 

The color varied a good deal in the different species of black 
vomit : in some, it was a dark chocolate brown ; in others, a 
brownish black; in others, again, more especially in the hsemate- 
mesis of the hemorrhagic form of the disease, the color was that 
of very dark but otherwise apparently little altered blood. When 
allowed to rest for any time the black vomit spontaneously sepa- 
rated into two portions; a more or less clear supernatant fluid, 
and a powdery or occasionally flocculent deposit, the color of 
which was commonly that of the black vomit itself, only a little 
more intensified. The specific gravity of the fluid before deposit 
had taken place, was ascertained to be pretty constantly 1007: it 
sometimes reached 1008, but I have not known it higher than 
1009. The reaction was invariably acid : no change whatever 
took place on boiling, or on the addition of nitric acid. By fil- 
tration a clear transparent fluid passed through, while a powdery 
matter of the color of the original black vomit remained on the 
filter. The black vomit remained unchanged for days, with the 
exception of developing minute cryptogamic vegetations. 

The Barreswill fluid gave, with the clear filtered fluid, a beau- 



CHAKACTEKS OF BLACK VOMIT. 311 

tiful purplish tint with flocculent deposit; liquor potassse boiled 
with this filtered fluid gave a dark flocculent deposit; when eva- 
porated to dryness, this fluid (the clear filtered liquor) left a 
brownish and somewhat glutinous residuum with a faint smell of 
caramel. No characteristic reactions were obtained except that 
with nitrate of silver, which gave abundant white cloudy precipi- 
tate from the chlorides present. But in fact when the total 
absence of biliary coloring matter of any kind was put beyond 
question by the use of a few simple reagents, little further attention 
was bestowed on the chemical composition of this fluid. It may 
be remarked that it was never found to contain any trace of 
albumen. 

On microscopic examination, variously altered blood elements 
were observable: generally speaking, blood-corpuscles were not 
discoverable as such even in the most recent black vomit (of the 
ordinary kind) in any considerable quantity. But this observa- 
tion is not to be understood as applying to the hematemesis of 
the hemorrhagic form, in which blood-corpuscles in abundance, 
and but little if at all altered in physical characters, were readily 
observed. The ordinary, and so to speak the true black vomit, 
presented under the microscope innumerable minute irregularly 
formed particles, of a dark reddish or brownish tint, variously 
aggregated into masses with but very few blood-disks recogniz- 
able as such. Flattened and otherwise altered corpuscles, with 
or without milled edges, were found in some specimens; many 
corpuscles were found aggregated together in masses, while others 
were variously broken up. No crystallization or even molecular 
aggregation of the coloring matter of the blood was observed by 
me in any instance. 

I may remark that the characters here given agree in all essen- 
tial respects with those presented by the black vomit of cancer of 
the stomach. Specimens of both the black vomit of yellow fever 
and of cancer of the stomach now in my possession are quite 
undistinguished by any chemical or microscopical character, or 
by any physical character whatever with which I am acquainted. 
The specific gravity of the specimens from cancer of the stomach 
(scirrhus pylori), it may be observed, reached 1015, while that of 
the black vomit of the Lisbon yellow fever never exceeded 1009. 

In the black matter found in the stomach and intestines post 
mortem, blood-corpuscles were generally present in abundance ; 



312 PATHOLOGICAL AXATOMY OF YELLOW FEVER. 

besides these elements, epithelial scales, nuclei, and other debris 
of the mucous surface, were observed ; but I have already re- 
marked on the total absence from the intestinal contents of any 
fragments of vascular tissue, no more definite elements of tissue 
than cells, nuclei, molecular, and minute indefinite particles having 
ever been found, though particular care was bestowed on the 
examination of the intestinal contents. 

State of the Mucous Surface. — The mucous surface was gene- 
rally intact, the epithelial layer perfect, and no evidence of de- 
composition was observable. No detachment of any parts of the 
mucous surface was observed to have taken place under any cir- 
cumstances. And from the condition of thiugs observed, I can- 
not, for my own part, conceive the possibility of such an occur- 
rence as the detachment of fragments of the capillary vascular 
tissue of the mucous membrane. It has been stated on recent 
authority, that such fragments have been found in the stools of 
yellow fever patients. No such thing certainly occurred in the 
Lisbon epidemic, and the state of the mucous surface above de- 
scribed leads me to doubt the probability of this occurrence. 

No lesion of the glandular apparatus was detected. The state 
of the solitary and aggregate follicles was either that of perfect 
health or of slight commencing retrogression, evidenced by the 
reticulated state and partially shrivelled condition of Peyer's 
patches. This state corresponded to what we know of the normal 
retrogression of these parts. 

Occasionally one or two isolated patches of ulceration were 
found on the mucous surface: in the jejunum in one instance, in 
the ileum on one or two occasions, and in the colon. They were 
commonly shallow superficial excavations, and in all probability 
of long standing, and had obviously no connection with the dis- 
ease of which the patient died. They were in no way connected 
with the occurrence of any form of hemorrhage, and were alto- 
gether wanting in the best-marked hemorrhagic cases. 

(Edema of Mucous Tissue. — An oedematous state of the mucous 
surface was observed in some few instances. The membrane was 
raised up into many ridges, \ to \ inch in thickness ; this pecu- 
liar state sometimes engaged a large tract of the mucous surface. 
I have observed it in the small and also in the large intestines. 

Mesentery and Mesenteric Glands. — We have already considered 
the enormous deposits of fat found occasionally in the mesentery. 



MORBID STATES OF LIVER. 813 

A state of intense vascular injection was pretty commonly observ- 
able. Occasionally the mesenteric glands were found enlarged 
and congested ; more rarely their substance was found on section 
deeply gorged with dark venous blood. 

Liver. — The most remarkable, the most constant, and, to my 
mind — I will frankly avow it — the most inexplicable condition 
presented in the post-mortem examination of fatal yellow fever 
cases, was the state of the liver. I believe it may be affirmed 
that some departure from the normal state of this organ was an 
absolutely constant condition in all the cases which proved fatal. 
It was not only so with regard to the cases examined by myself, 
but the concurrent testimony of all my learned confreres in Lisbon 
pointed to the same result. 

Color of the Liver. — The most frequent and remarkable change, 
and that which immediately attracted attention in the majority 
of cases, when the abdominal cavity was first opened, was a more 
or less well marked yellow coloration. The color most frequently 
presented was that of a rich fawn yellow, or buff color. Various 
shades of this color were observable in different cases. In indi- 
vidual examples the color was, generally speaking, pretty uniform 
throughout the surface of the organ, both on the superior and 
inferior aspect, and in both lobes; it was likewise uniform through- 
out the deeper hepatic substance on section in every part of the 
liver. Patches of a brighter yellow were sometimes interspersed 
through the general fawn or buff colored tint. "Various grada- 
tions in tint were observable in different cases, from the fawn- 
yellow color here described to a yellowish brown tint, chocoht 
au hit. 

The ordinary liver-brown color was sometimes presented even 
in cases in which changes in the hepatic substance were shown 
upon further examination. 

The fawn yellow was sometimes interspersed with minute 
stellate, or in other instances mere punctiform spots of reddish 
vascular injection. This injection was observable on the surface 
and in the substance of the organ. 

In some few cases a well-marked nutmeg state of the organ 
was presented. In one well-marked instance this state was com- 
bined with an amount of change in the hepatic tissue such that 
its specific gravity fell to 4| (areometer of Beaume). 

The fawn-yellow color hfis been observed as a partial condi- 



314 PATHOLOGICAL ANATOMY OF YELLOW FEVEE. 

tion, either predominating and interspersed with patches of the 
liver-brown tint, or in other instances this latter color prevailed, 
and the fawn-yellow was distributed in patches of irregular size 
and shape. This piebald condition was observable on the surface 
and throughout the substance of the liver on section. 

Purpuric spots have been found upon the surface of the liver. 
This condition was usually present in other internal organs at 
the same time — on the heart, oesophagus, duodenum, stomach, or 
kidneys. 

The hepatic substance was pretty firm, and resistant to the 
touch. It was in some instances shown to be rather dryish on 
section. It was never soft, flabby, or greasy, and in no instance 
presented evidence of advancing decomposition, except in the 
case of acute decomposition already noticed. The hepatic tissue 
at the same time never presented that density of texture re- 
markable in the lardaceous or bacony liver. The organ was 
seldom much enlarged, and equally rarely diminished in volume. 

In three instances the total weight of the organ was deter- 
mined at 50, 56, and again 56 ounces respectively. 

It was very commonly remarked that there was an absence of 
the ordinary yellow or greenish biliary staining of the under 
surface of the liver. The hepatic flexure of the colon and other 
contiguous parts of the peritoneal and visceral surfaces were 
likewise free from biliary staining. For a well-marked excep- 
tion, with characteristic change in the liver, see case 24, Table 
II. p. 57, Parliamentary Eeport. 

Gall Bladder. — Bile, normal in amount and character, has been 
found in the gall bladder, but only rarely so. Generally speak- 
ing, the gall bladder was distended, and contained from two to 
four, or even six or eight, ounces of reddish-black thick fluid. Its 
mucous surface was stained of a similar color. In these instances 
there had been unquestionably more or less profuse hemorrhage 
into this sac. On microscopic examination blood corpuscles 
were found in abundance. This hemorrhagic effusion was the 
more remarkable inasmuch as the gall bladder presented in some 
instances the only example of mucous hemorrhage after death. 
In one or two instances only were biliary calculi found in the 
gall bladder. 

Microscopic examination of Hepatic Tissue. — The fawn-yellow 
coloration usually well indicated the%hange that had taken place 



FATTY CHANGE IN LIVER. 315 

in the hepatic tissue ; but it was not only in those cases in which 
the liver presented this coloration that abnormal states of the 
hepatic structure existed. The yellowish-brown color, chocolat 
au lait, was attended with similar and fully as well marked 
changes. The same may be said of the nutmeg condition of the 
organ, and even to some extent of several cases in which the 
ordinary liver-brown color was unchanged. 

Minute fine sections (by Valentin's double knife), or matter 
scraped from the hepatic texture, exhibited the hepatic cells filled 
with globular oily and fatty matter. The natural appearance of 
the cell was completely altered, its outlines obscured, and its 
nucleus rendered invisible. It was surcharged with molecular 
and globular oily matter, while the whole field, and the inter- 
spaces between the cells, were filled with similar and equally 
abundant oily and fatty elements. 

When carefully treated with ether, the oily and fatty elements 
were in part dissipated, and the contour of the cells brought 
more clearly into view, but it was only rarely that the nucleus 
could, even by long treatment in ether, be made visible. 

It was sufficiently obvious from these investigations, that the 
marked character of the hepatic lesion was that of fatty degene- 
ration, with accumulation of fatty elements in the otherwise 
normal hepatic cells. 

Eesearches with the microscope, however carefully made, were 
found to give but imperfect and unsatisfactory determinations of 
the positive and comparative amount of fatty deposit in the 
hepatic tissue. I determined, therefore, to estimate the specific 
gravity of the organ in a good many cases, with a view to a more 
accurate appreciation of the amount of change thus induced; it 
being of course fairly presumable that in proportion to the amount 
of fatty accumulation in the hepatic structure the specific gravity 
of the organ would be found diminished accordingly. 

The general results were uniformly found to bear out this pre- 
sumption. It was ascertained that, in general, the fawn-yellow 
color of the liver corresponded with abundant granular and 
molecular fatty matter in the hepatic cells, as shown by micro- 
scopic examination, and with diminished specific gravity of the 
liver substance, as shown in the manner presently to be described, 
by the areometer of Beaume*. The results thus obtained were 
further confirmed by the determination of the absolute quantity 



316 PATHOLOGICAL ANATOMY OF YELLOW FEYEK. 

of ethereous extract in given weights of hepatic substance in 
different cases. 

The following Table gives the results obtained bjthe areometer 
of Beaume' employed to determine the specific gravity of the liver 
in different cases. 

The mode of procedure was as follows: Avery strong solution 
of common salt 1 was made in a glass vessel of suitable height. 
The areometer of Beaume was allowed to float freely in this 
vessel. Small cubes of hepatic substance were cut from the 
central parts of the liver, and immersed in the fluid: if they sank 
an additional quantity of salt was carefully added ; if they floated 
'high upon the surface, water was gently poured into the solution. 
In either case, the precise moment was carefully observed when 
the cube of hepatic substance, after having assumed a position 
between floating and sinking, and having oscillated slightly up 
and down, seemed for an instant or two to be in equilibrium; the 
degree marked upon the areometer was then recorded as accu- 
rately as possible. But as the instrument marked only whole 
degrees, the readings of fractional parts of a degree could not be 
taken with all the accuracy desirable. In recording the obser- 
vations, care was taken to allow the error of sight to be on the 
side of the greater rather than the less specific gravity. 
■ For the purpose of comparison, the specific gravities of two 
specimens of liver taken from cases which did not die of yellow 
fever are placed at the top of the column. 

One of them — that of a case of suicide — may be supposed to 
represent the normal condition of the organ as nearly as possible. 
Death took place after an incision of the throat, implicating the 
vessels of the neck, in less than twenty-four hours. In the other 
case no appreciable alteration of the organ was present. 

It will be seen that there is a general correspondence between 
yellow coloration and low specific gravity, but the relation is not 
a constant one by any means. Thus the liver was yellowish- 
brown, with a specific gravity of 7J° in No. 21, while in No. 25 
it was very yellow, with a higher specific gravity by half a de- 
gree. I conclude, then, the specific gravity to be a more accurate 
measure of the fatty change than that furnished by the mere color 
of the hepatic substance. 

1 This, though not the most suitable agent for estimating the specific gravity 
of animal tissues, was the only one readily available. 



SPECIFIC GKAVITY OF LIVEE SUBSTANCE, 



317 



Table of Specific Gravity of Liver. 
(Determined by the Areometer of Beaume, in Solutions of Chloride of Sodium.) 



No. 


Sex. 


Age. 


State of liver. 


Specific 
gravity. 


A 


Man (soldier) 


35(?) 


Case of suicide by incision in throat ; 
death within 24 hours ; liver perfectly 
normal in appearance 


10° 


B 


Man 


40 (?) 


Did not die of yellow fever ; liver quite 
normal in appearance 


10 


1 


Man 


50 


Liver yellowish-brown color 


8| 


2 


Woman 


40 


Liver yellowish-brown color 


9 


3 


Man 


55 


Liver brown ; normal .... 


10 


4 


Woman 


40 


Liver very yellow color 


7 


5 


Man 


45 


Liver yellowish color .... 


7? 


6 


Man 


? 


Liver brownish color .... 


9 


7 


Woman 


45 


Liver yellow color .... 


7* 


8 


Woman 


? 


Liver yellow color .... 


7 


9 


Man 


40 (?) 


Liver brown color .... 


9 


10 


Woman 


60 


Liver yellowish color . . . 


9 


11 


Man 


? 


Liver yellowish-brown color 


8 


12 


Man 


23 


Liver yellowish color .... 


9 


13 


Man 


20 (?) 


Liver yellow color .... 


8 


14 


Man 


? 


Liver very yellow color; weight 60 
ounces ...... 


6| 


15 


Man 


45(?) 


Liver mottled yellow color ; nutmeg . 


4| 


16 


Man 


30 


Liver yellow color .... 


8 


17 


Man 


20 (?) 


Liver yellow color .... 


7 


18 


Man 


25 (?) 


Liver brownish color .... 


H 


19 


Man 


25 (?) 


Liver yellow color .... 


H 


20 


Woman 


34 


Liver very yellow color 


nh 


21 


Woman 


62 


Liver yellowish-brown . . 


n 


22 


Woman 


55 


Liver yellow color .... 


7; 


23 


Man 


20 (?) 


Liver yellow color .... 


7 


24 


Man 


16 


Liver very yellow color . . . 


7.} 


25 


Man 


40 


Liver very yellow .... 


8 


26 


Woman 


? 


Condition not stated .... 


9,| 


27 


Man 




.... 


8$ 


28 


Man 




, 


..... 


10 


29 


Woman 




. 


. 


3£ 


30 


? 


? 


. . 




7| 


31 


? 


? 


. , 


..... 


6£ 


32 


? 


? 


. 


. 


7i 


33 


? 


? 






H 


34 


Man 


30 (?) 


Liver very yellow color 


Xi 



DETERMINATION OF ABSOLUTE QUANTITY OF FATTY MATTER 

IN LIVER. 

With a view to determine this part of the question, known 
quantities of hepatic substance were macerated in sulphuric ether 
for 48 hours, and sometimes for a longer period, in stoppered 
bottles. The bottles, capsules, filters, and hepatic residue were 
all carefully weighed. The evaporations of the ethereous extract 



318 



PATHOLOGICAL ANATOMY OF YELLOW FEVER. 



were conducted with all due precautions, and as nearly as possi- 
ble under similar circumstances in all the cases. One ounce of 
"hepatic substance, cut into minute fragments, was macerated in 
two ounces of ether. 



Abstract of Weight of Ethereous Extract from One Ounce of Hepatic 
Substance after Careful Evaporation. 







o£> 






Percentage 


No. 


Quantity of 
hepatic substance. 




State of liver. 


Weight of 
ethereous extract. 


of 
ethereous 
extract. 










Grains. 




A 


1 oz. of hepatic 
substance 


10° 


Apparently healthy 


Gave after eva- \ „a 
poration ) 


15.416 


B 


" " 


10 




95J 


19.791 


1 


it it 




Yellow or chocolate 
colored 


111 


23.125 


2 


ii u 






" 95 


29.791 


3 


" " 












148 


30.833 


4 


it it 












171 


35.625 


5 


il it 


"n 










116 


24.166 


6 


u a 


7 










167 


34.791 


7 


a a 


7 










" 201 


41.875 


8 


a it 


9| 










79 


16.458 


9 


a a 


8| 










" 86 


17.916 


10 


a ti 


10 










84 


17.555 



Two livers, apparently healthy, were submitted to examination 
in the same matter. One was that of the soldier who committed 
suicide, and in whom no trace of disease of any kind was found ; 
the other was that of a patient of the hospital St. Jose not affected 
with yellow fever, and in whom the liver appeared to be in a 
normal state. The other specimens were all from yellow fever 
patients, and the hepatic substance was variously colored, from 
fawn or buff yellow to chocolate color, and from that to the ordi- 
nary hepatic brown tint. The results are generally conformable 
to what we have already stated. Some exceptions occur in the 
last three cases, upon which it will be necessary to observe. 

These observations are, of course, too limited to admit of 
general conclusions being drawn from them in an absolute 
manner. They prove, however, that with the yellow or buff 
colored, or* even the chocolate-colored state of the hepatic sub- 
stance, there was found in the cases cited a considerable, and, in 
some instances, a very marked, increase of the fatty elements. 
We have already shown that by the microscope and the areometer 
a corresponding result was obtained. There is an apparent ex- 



SUGAK IN LIVEK. 319 

ception to this statement of the results in the last three instances 
in the Table, see Nos. 8, 9, and 10. 

With regard to No. 8, the specific gravity is recorded as 9f, 
which is, as already stated, a little under rather than over the 
mark, and if 10 be considered the normal average, the departure 
from the normal specific gravity, and in all probability from the 
normal state of the hepatic substance, was but inconsiderable. 

In the instance of No. 9, the specific gravity was undoubtedly 
diminished : it is recorded as only 8J°. The patient, however, 
had been in hospital from the 19th of November to the 24th of 
December, and the case was, therefore, one which had passed 
through all the periods and ordinary stages of the fever. The 
case might therefore be omitted from the present category alto- 
gether. 

In No. 10 the specific gravity of the hepatic substance is re- 
corded as 10 (by the areometer). The yellow fever condition 
probably no longer existed. 

Sugar in the Liver, — Some examinations, both qualitative and 
quantitative, were made to determine the state of the saccharific 
function of the liver. The following are the general results 
obtained : — 

In cases fatal within the first period of the disease, the hepatic 
tissue gave the characteristic saccharine reaction with the Barres- 
will fluid, cupro-potassic solution. 

In cases of longer standing, which had passed into the second 
or third periods, the reaction with the Barreswill solution was 
extremely faint, and in some instances was altogether absent. 

I have in some cases obtained slight but appreciable reaction 
with the liquor-potassas test, with the production of a faint but 
characteristic odor of caramel. 

Spleen. — The spleen has not been found to present any constant 
pathological characters of importance. It has been found of 
normal volume and without appreciable lesion of any kind. It 
was occasionally found enlarged by one or two volumes, much 
gorged with blood, and its tissues in consequence readily gave 
way under pressure. But I have failed to detect any morbid 
condition having manifest special relation to the lesion at large, 
or to the states of other organs, as, for instance, the stomach and 
liver. 

In some few instances diminution, to a small extent, of the 



320 PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

volume of the organ has been noted. A very small and con- 
tracted spleen has been recorded only in one or two cases. 

The absence of more marked and prominent lesion of this 
organ, supposed to be so much implicated in the sanguific process, 
I look upon as being of no small interest in a negative way. 

Kidneys. — These organs were carefully examined in all instances. 
They were, it may be said, very commonly implicated so far as 
general engorgement of their structure, whether in the cortical or 
pyramidal part, or in both. 

Congestion to some extent has been all but constant in the 
renal substance in both organs. Two states were distinguishable 
in different cases; one that of active vascular injection, the other 
that of general and diffuse hemorrhagic engorgement. 

Amongst the few examples of non-congestion of the renal sub- 
stance, the most remarkable were those in which there was a 
general yellowish color of the surface with purpuric spots, well- 
marked and thrown out conspicuously by the contrast of color. 
The purpuric spotting of the kidneys was never an isolated con- 
dition, but was always associated with the same phenomenon in 
other parts and organs. 

A fatty state of the cortical part with congestion of the pyra- 
mids has been observed. This and the foregoing conditions, as 
well as some few instances of the waxy degeneration of the organs, 
were of very un frequent occurrence, and had no obvious connec- 
tion with the disease of which the patient died. 

The usual microscopic appearances were presented in these 
cases when sections with Valentin's knife were placed in the 
field. Separation of the tubules with degenerated cells, and much 
oily matter, pus, and broken cells, were conditions occasionally 
observable. 

In one or two cases, small purulent cysts were found dissemi- 
nated through the kidneys. 

The Bladder. — A moderate quantity of urine variable in appear- 
ance has been found in the bladder: sometimes but a few drachms, 
in other instances 8 to 12 ounces or even more. It was generally 
clear, straw-colored, or amber yellow, occasionally coagulable, but 
more commonly unaffected by heat or nitric acid. 



ILLUSTRATIVE CASES. 321 

TABLE . 

OF APPEARANCES PRESENTED POST MORTEM IN CASES OF YELLOW FEVER. 

No. 1. Female; aged 40. External Surface. — Body yellow, and 
thickly covered with purpuric spots. Marks of hemorrhage about the 
month and on gums. No unusual amount of blood was observed in the 
muscles or other tissues in this case. 

Cranial Cavity. — Congestion of cerebral surface; brain substance 
presented the sable condition (spotted with the red points of vessels cut 
across). The ventricles contained much bloody serum. The sinuses 
were likewise congested. 

Thoracic Cavity. Lungs. — Both lungs were congested throughout. 
Heart. — The heart was in a slightly fatty condition; both ventricles 
containing some dark fluid blood, but no clots or fibrinous coagula 
whatever. 

Abdominal Cavity. — The surface of the intestines was yellowish in 
color. They were moderately distended, but not congested. The Sto- 
mach. — This organ contained no blood; there was slight erosion of the 
epithelium at the cardiac termination of the oesophagus. There was no 
blood effused in any portion of the intestinal tract, and the mucous sur- 
face presented nothing remarkable. 

Liver.— This organ was of a general fawn-yellow color, with here and 
there small patches which were quite yellow; the surface was also spot- 
ted here and there with reddish points. It gave by the areometer of 
Beaume a specific gravity of 9. The gall-bladder contained about half 
a pint of thick fluid, of a dark red aspect. This fluid presented under 
the microscope blood-corpuscles in abundance. 

Kidneys. — These organs were slightly congested. 

Observations. — This case had been but four days ill ; the patient was 
delirious. 

The gall-bladder was the seat of considerable hemorrhage (8 oz.). 

It was the only one of the mucous surfaces on which blood was effused. 

No. 2. Male; aged 50. External Surface. — The body was yellow 
and partially covered with purpuric spots. The muscles were rigid, and 
their outlines well, shown through the integuments, especially in the 
extremities. The feet were curved inwards, the toes pointed, and the 
heels elevated. 

Cranial Cavity. — Some congestion of the cranial cavity existed, but 
only to a slight extent. There was some serosity and opacity of the 
arachnoid. The cerebral substance was rather dry ; only a slight amount 
of serosity was observed in the ventricles of the brain. 

Thoracic Cavity. Lungs. — These organs were here and there spotted 
black; they were deeply congested throughout. Heart. — The heart 
contained blackish fluid blood in small quantity, but no clots or fibrinous 
coagula. It was not otherwise remarkable. 

Abdominal Cavity: Stomach. — Spots of congestion were observable 
on the mucous surface of this organ. Small Intestines. — The small 
intestines were much congested, as were also the upper parts of the 
colon (6 to 8 inches of this gut near the ca3cum). The intestines con- 
tained a quantity of reddish bloody fluid, hemorrhagic exudation from 
the congested mucous surface. 
21 



322 PATHOLOGICAL ANATOMY OF YELLOW FEVEE. 

Liver. — The liver was of a pretty uniform yellowish-brown color. It 
was ascertained by the areometer of Beaume to have a specific gravity 
of 8-J. 

Spleen. — There was nothing observable about the spleen. 

Kidneys. — These organs were a good deal congested throughout their 
structure, both in the cortical and pyramidal parts. 

Observations. — This was an example of the sthenic form in which 
death took place very unexpectedly. The patient was only 1J days in 
hospital. Pyrexia was pretty well developed. He became delirious and 
could be retained in bed only by constant watching; but the strength 
appeared little diminished till shortly before death. 

No. 3. Male; aged 55. External Surface. — The surface generally 
was deeply congested, especially in the dependent parts. There was 
but slight yellow coloration, and there was an entire absence of purpuric 
spots. 

Cranial Cavity. — There was but slight subarachnoid effusion, and 
but a small quantity of serum in the ventricles of the brain. The .cere- 
bral substance itself presented nothing abnormal. 

Thoracic Cavity: Lungs. — The pulmonic substance generally was 
much congested. The heart contained little or no blood, and was not 
otherwise remarkable. 

Abdominal Cavity. Stomach. — The stomach was much contracted, 
and on being laid open presented much dark punctiform congestion. 
The duodenum presented numerous small hemorrhagic spots. 

The intestines contained a dark greenish matter in considerable quan- 
tity. There was a general cedematous state of the mucous membrane, 
especially in the ileum ; it was raised into soft wavy elevations J inch 
or more in depth. The upper part of the colon near the caecum pre- 
sented three shallow, oval-shaped, ulcerated excavations, each about J 
an inch in the long axis. 

Liver. — The liver was of a yellowish-brown, spotted (nutmeg) appear- 
ance, and gave a specific gravity of 10. The gall-bladder contained a 
small quantity of yellowish bile. 

Kidneys. — Both kidneys were somewhat enlarged and much cougested. 

Observations.* — Yellow coloration but little marked in this case after 
death. 

Hemorrhagic spots were found in the duodenum, and there was an 
cedematous state of the mucous membrane in the ileum. 

No. 4. Male ; aged 45. External Surface. — General yellow colora- 
tion of the external surface was presented. 

Cranial Cavity. — Some bloody serum was observed under the arach- 
noid. The cerebral surface on section of the hemispheres presented 
the sable condition in both hemispheres. There was much serum in 
the ventricles. 

TJwracic Cavity. — The lungs were much engorged throughout. The 
heart contained much blood in the right chambers, with well-formed 
yellow fibrinous coagula 

Abdominal Cavity. — The stomach was deeply injected and of a dark 
purplish color. Punctiform vascularity was observable here and there. 
The jejunum was slightly congested. It presented a slight appearance 



ILLUSTRATIVE CASES. 323 

of the "sago-grain" state of its solitary follicles (milky injection). 
Peyerh patches presented a reticulated appearance throughout. 

Liver. — This organ was of a slightly yellowish color, but its external 
appearance, and even that on section, gave only an imperfect idea of 
the peculiar alteration it had undergone by fatty deposit in the cells of 
the hepatic substance. The specific gravity was found to be only t^. 

Kidneys. — Both these glands were congested. Several small cysts 
were likewise found in both. 

Observation. — In this case the departure from the normal condition 
in the liver was rendered evident only by the areometer. 

No. 5. Female; aged 40. External Surface. — The body was yellow, 
but the surface was not otherwise remarkable. 

Cranial Cavity. — There was much injection and some bloody effusion 
on the surface of the hemispheres of the brain. On section the cerebral 
substance was found very much sable. 

Thoracic Cavity: Lungs. — No remarkable state of the pulmonary 
structure is recorded. Heart: The heart was small, and was covered 
with numerous purpuric spots, which were found on both ventricles and 
auricles, especially on the right ventricle. Some similar spots were 
observable on the lining membrane of the right auricle. There was a 
distinct ecchymosed patch near the foramen ovale. There was one spot 
on the endocardium of the right ventricle. 

Abdominal Cavity. Stomach. — Several hemorrhagic spots were ob- 
servable on the mucous surface of this organ ; and on following up the 
oesophagus it was likewise found to present hemorrhagic or purpuric 
spots. 

The jejunum was congested, and presented one circular red ulcerated 
patch, about J inch in diameter. The ileum was likewise injected, and 
striated vascularity of the lower sets of PeyerH patches was observable. 

Liver. — The liver was of a well-marked fawn-yellow tint. Several 
purpuric spots were observable on its surface. The specific gravity was 
only 1. 

Kidneys. — These organs were both of a yellowish color, showed here 
and there several purpuric spots, but were not otherwise altered. 

Observation. — The record of this case states that there was no black 
vomit, and no mention is made of any other form of hemorrhage having 
been presented during life. Purpuric spots were presented on various 
internal organs after death. This case has important bearings on the 
general pathology of the disease. 

No. 6. Male ; aged 45. External Surface. — The body was that of 
a robust and vigorous man in the prime of life. The muscular outlines 
were well defined through the integuments. The conjunctivae were yel- 
low. The surface generally was but slightly yellow. The cheeks, fore- 
head, sides of the head, neck, and parts of the shoulders were deeply 
tinged with purplish blood stains. The superficial veins in the same 
situations were engorged and prominent. The whole of the posterior 
and lateral aspects of the trunk and extremities were of a livid hue. 
The muscles, and other tissues, on section, were everywhere deeply 
stained with blood. The hands and feet were contracted, the latter with 
the toes pointed, the heels elevated, and the soles inclined inwards. 



324 PATHOLOGICAL ANATOMY OF YELLOW FEVEE. 

Cranial Cavity. — The sub-arachnoid spaces were filled with effused 
blood. The surface of both hemispheres and of the cerebellum was 
everywhere deeply congested. The brain on dissection presented the 
sable condition well marked. 

Spinal Canal, — The rachidian system was vastly gorged with blood, 
and the membranes of the spinal cord much congested. The cord itself 
on section was sable. 

Thoracic Cavity. Lungs. — The lungs were engorged and congested 
throughout, and collapsed but little when the thorax was laid open. 

Heart. — This organ was filled in all its chambers with semi-fluid black 
blood. Its muscular structure, as well as its external and internal serous 
covering, was deeply tinged with blood, and of a very dark red color. 

Abdominal Cavity. — The intestines were deeply congested and of a 
livid hue. Stomach. — The stomach was of a uniform deep purple color 
throughout. It contained a quantity of black semi-fluid and but little 
altered blood, which was likewise found in the intestines. 

Liver. — The liver was of a uniform brownish color. The gall-blad- 
der was filled with a quantity of black bile and blood mixed. The spe- 
cific gravity of the hepatic substance was 9. 

Observation. — This case constitutes the most marked example of the 
hemorrhagic form, of which it may be taken as the type. 

No. 7. Male; aged 40. External Surface. — There was marked con- 
gestion of the penis and testicles, also of both feet and of left leg. The 
body was much emaciated ; there was no yellow coloration. 

Cranial Cavity. — There was some slight opacity of the arachnoid, 
also some slight sub-arachnoid effusion ; there was a more considerable 
amount of serosity in the ventricles. 

Thoracic Cavity. Lungs. — The lungs were gray and but moderately 
congested posteriorly. Heart. — Some serum (1 to 2 oz.) was found in 
pericardium ; the right and left ventricles contained large clots. 

Abdominal Cavity. Stomach. — Stellate congestion was observable 
here and there on the mucous surface of this organ. Patches of ecchy- 
mosis were found in some parts of the duodenum. Congestion of the 
jejunum and ileum to a slight extent was observable. Some of Peyerh 
patches presented a punctiform injection. Ordinary fecal matter was 
found in the intestines. The colon exhibited two or three small points 
of ulceration near its csecal end. The mesenteric glands were congested. 

Liver The liver was brown in color, not otherwise altered, and gave 

a specific gravity of 9. The spleen was twice its normal volume. The 
kidneys were congested. 

Observation. — This was one of the few cases in which emaciation of 
the body was observed. 

No. 8. Female ; aged 45. External Surface. — The body presented 
a general bright canary color. 

Cranial Cavity. — Slight congestion of the surface of the cerebral 
hemispheres existed. 

Tlwracic Cavity. Lungs. — The right lung presented numerous apo- 
plectic patches ; the left also exhibited points of hemorrhagic effusion 
into the pulmonary substance, but to a less extent. 

Heart. — The pericardium contained an ounce or two of serum. The 
ventricles contained black semi-fluid blood. 



ILLUSTRATIVE CASES. d2o 

Abdominal Cavity. Stomach. — This organ presented large patches 
of congestion in the great curvature. The jejunum was moderately con- 
gested. One ulcerated patch was found in the ileum ; it was a shallow 
excavation J inch in diameter, with red edges. The colon was slightly 
congested, and presented some few red patches. 

The bladder was distended with straw-colored urine. 

Liver. — The liver was yellow in parts ; the gall-bladder contained 
black bile. The hepatic substance gave a specific gravity of %\. The 
spleen was slightly enlarged. The kidneys were slightly congested. 

Observation. — This case presented an example of perhaps the bright- 
est yellow coloration observed. 

No. 9. Female. External Surface. — The body was but very slightly 
yellow. 

Cranial Cavity. — No observation recorded. 

Thoracic Cavity. — No observation recorded. 

Abdominal Cavity. — The stomach presented a general pink injection. 
The duodenum was congested, as also were the jejunum and ileum. The 
colon presented a more vivid red injection than the other parts. Much 
black matter, altered blood, was found in the ileum. 

Liver. — The liver was of a uniform yellow-brown color, not other- 
wise altered in appearance, and gave a specific gravity of 7. The spleen 
was slightly enlarged. 

Observation. — This case presented an example of the pink vascular 
injection of the stomach ; but this organ did not contain effused blood. 

No. 10. Male; aged 23. External Surface. — Body but very slightly 
yellow. 

Cranial Cavity. — Hemispheres of brain congested slightly. Cerebral 
substance slightly sable. 

Thoracic Cavity. Lungs. — Both organs were much congested. The 
heart was contracted, and contained but little blood. 

Abdominal- Cavity. Stomach. — The stomach was filled with black 
vomit ; its mucous surface presented much stellate injection. The in- 
testines were likewise filled with black matter ; altered blood. 

Liver. — The liver was yellowish, and gave a specific gravity of 9. 
The spleen was of ordinary size. Kidneys. — Both kidneys were much 
congested. 

Observations. — This patient was taken sick on the 3d, and died on 
the 10th of December. 

Stellate injection of stomach which contained much black vomit. 

No. 11. Male ; aged 25(?). External Surface. — A peculiar mulatto- 
like tint was observable in this case, both during life and after death. 

Cranial Cavity. — Slight congestions of the hemispheres existed. The 
cerebral substance was but slightly sable. 

Thoracic Cavity. Lungs. — Both these organs congested but slightly. 
Heart. — Some serum (1 to 2 oz.) in pericardium. The ventricles con- 
tained black semi-fluid blood, but no clot. 

Abdominal Cavity. Liver. — The liver was yellowish, and gave a 
specific gravity of 8. Spleen normal. Kidneys slightly congested. 

Observation. — Peculiar mulatto-like tint observable both before and 
after death in this case. 



326 PATHOLOGICAL ANATOMY OF YELLOW FEYER. 

Xo. 12. Female; aged 60. External Surface. — This woman was of 
enormous obesity. The surface was yellow, but with large livid patches 
on the dependent parts. Large excoriations, with bloody exudation, 
existed in the folds of the axilla and groin on both sides. Blood 
trickled from the nose. General congestion of the muscles was ob- 
served on section. 

Cranial Cavity. — There was some superficial congestion of the right 
hemisphere of the brain. The cerebral substance was slightly sable. 
There was much congestion of the vertebral veins. 

Thoracic Cavity. Lungs.' — Congestive semi-pneumonic solidification 
of the anterior part of the right lung existed. Heart. — Some few clots 
were observed in the right ventricle ; the left was well contracted. 

Abdominal Cavity. — Enormous deposits of fat existed between the 
several layers of abdominal muscles. The mesentery was loaded with 
masses of fat, several inches in thickness. The intestines generally 
were contracted and much congested. The stomach was deeply con- 
gested, but presented no hemorrhagic effusion. The duodenum was of 
a dark congested appearance. The colon was much congested, and of 
a dark color externally ; the mucous surface was thickened, softened, and 
reddish. The intestines contained throughout natural fecal matter. 

Liver. — This organ was somewhat enlarged, of a general mottled 
(nutmeg) aspect ; it gave a specific gravity of 9. The spleen was small. 
The kidneys were yellowish (fatty) in the cortical part throughout, 
while the pyramids were much congested. 

Observation. — Amount of adipose deposit in this case was most re- 
markable. The internal organs were loaded with fat. 

No. 13. Male; aged 45(?). External Surface.— Intense and almost 
universal livid congestion of the surface of the body existed. This was 
especially observable on the face, and on the posterior parts of the truuk. 
The color is noted as of a blue-black. This was another instance of 
intense hemorrhagic staining of the integuments, as if the principal 
tendency of the hemorrhagic action was towards the cutaneous surface. 

Cranial Cavity. — The brain and its membranes were slightly con- 
gested. 

Thoracic Cavity. Lungs. — The lungs were universally congested. 
Heart. — -The substance of this organ was red and soft. 

Abdominal Cavity. Stomach. — The internal surface of this organ 
was deeply injected. Liver. — The hepatic substance was of a uniform 
brownish color, and gave a specific gravity of 8. Spleen. — This organ 
presented no remarkable alteration. Kidneys. — Both the kidneys were 
deeply congested. 

Observation. — This case presented another instance of the intense 
hemorrhagic staining of the integuments. The surface was the chief 
seat of the vascular lesion, 

No. 14. Female; aged 30. External Surface. — The body was that 
of a finely developed young woman in the prime of life and vigor. The 
conjunctivae were yellow ; the surface was but slightly yellow. 

Cranial Cavity. — This cavity was not examined. 

Thoracic Cavity. Lungs. — Both lungs were congested ; the left, 
more especially, was much enlarged, and adhered to the pleura. Heart. 



ILLUSTEATIVE CASES. 327 

— There was a small quantity of fluid, 1 to 2 oz. in the pericardium. 
Black fluid blood, with some clots and fibrinous coagula were found in 
the right ventricle. 

Abdominal Cavity. Stomach. — This organ was much distended. 
There was a general rose-colored congestion of its mucous surface ; it 
contained much black fluid (altered blood), which was likewise found in 
the duodenum. The intestines were much congested, as was also the 
mesentery. The ileum and colon were greatly contracted. Some yellow 
bile-colored matter was contained in the upper part of the ileum. All 
the remaining portions of the intestinal tract were filled with black inky 
fluid. 

Liver. — This organ was of a yellow color, weighed 56 ounces, and 
gave a specific gravity of 8. Kidneys. — They were but slightly con- 
gested. 

Observations. — The stomach in this case presents the rose-pink color- 
ation, and contained very much black blood. 

Yellowish bile-colored matter found in the ileum ; blackish inky fluid 
in the other portions of the intestinal tract. 

No. 15. Male. External Surface. — The body was slightly yellow, 
but not otherwise remarkable. 

Cranial Cavity. — The brain substance was pale and a little soft. 
There was a considerable amount of serous effusion beneath the arach- 
noid and in the ventricles. 

Thoracic Cavity. Lungs. — The lungs were much congested. Heart. 
— The left ventricle was well contracted, and the cavities contained but 
little blood. 

Abdominal Cavity. Stomach. — The gastric mucous surface presented 
stellate congestion. The termination of the oesophagus was red and 
vascular. The stomach and duodenum were botb filled with black mat- 
ter (altered blood); the remaining portion of the intestinal tube con- 
tained normal fecal matter. Liver. — The liver was very yellow, weighed 
50 oz., and gave a specific gravity of 6f. There was a considerable 
quantity of dark bile in the gall bladder, which could be readily made 
to flow through the ductus choledochus into the duodenum. Kidneys. — 
They were both congested, but not otherwise altered. 

Observation. — The stomach and duodenum contained blackish matter, 
feces in the rest of the intestinal tubes. 

No. 16. Male ; 50 (?). External Surface. — The conjunctivae were 
yellow ; the body was slightly yellow here and there ; the posterior sur- 
face and the extremities were lividly congested, and the legs presented 
very extensive patches of gangrenous erysipelas. 

Cranial Cavity. — There was some sub-arachnoid effusion of serum. 
The cerebral substance was a little soft. 

Tlioracic Cavity. Lungs. — Both lungs were slightly congested. 
Heart. — This organ was enlarged to three times its normal volume. 
Cretaceous patches were found in the aorta. There was extensive de- 
posit of calcareous matter on the semilunar valves of the aorta. Per- 
manent patency of the orifice existed, and there was remarkable hyper- 
trophy of the left ventricle. 

Abdominal Cavity. — There was general congestion of the intestines. 



328 PATHOLOGICAL ANATOMY OF YELLOW FEVER. 

Stomach. — The gastric mucous surface presented a large patch of red- 
dish congestion at the great curvature. Biliary matter was found in 
the intestines. Liver. — The liver was in the nutmeg condition, with 
yellow patches here and there. Its specific gravity was 4|. A few 
biliary calculi were found in the gall bladder. Spleen, Kidneys. — Both 
congested. 

Observation. — Results of gangrenous action observable on legs. 

No. -It. Soldier; aged 40. External Surface, — The body was well 
developed and muscular ; the hands and feet were contracted. The 
conjunctivae and surface generally were yellow. 

Cranial Cavity. — A yellow coloration of the dura mater was obser- 
vable on opening the cranium. There was slight but general serous 
effusion under the arachnoid. There was also slight congestion of the 
surface of the hemispheres. On section the cerebral substance was 
found to be only very slightly sable. There was much serum in the 
ventricles. 

Thoracic Cavity. Lungs.—Both lungs were much congested, but 
more especially the left. Heart. — The ventricles contained but a small 
quantity of semi-fluid dark blood. 

Abdominal Cavity. Stomach.— The organ was contracted. The 
gastric surface was generally congested, but there was an entire absence 
of black fluid of any kind. Liver. — The liver was yellow, and its 
specific gravity 7f . The spleen was enlarged by \ of a volume. The 
kidneys were firm but congested. 

Observation. — Yellow coloration observable in the dura mater. 

No. 18. Female ; aged 34. External Surface. — The body was yel- 
low, with large patches of dark livid congestion in the dependent parts. 

Cranial Cavity. — No record of any examination of this cavity. 

Thoracic Cavity. Lungs. — The lungs were both congested poste- 
riorly ; extensive splenization of the right was observable. Heart.^ 
The heart was adherent to the pericardium at the apex. There was 
but very little blood in the ventricles, and no clots or coagula. 

Abdominal Cavity. Stomach. — The stomach and duodenum were 
much congested ; congestion was likewise observed in the oesophagus. 
The stomach contained black vomit in abundance. The intestines like- 
wise contained much black matter, altered blood. Liver. — The liver 
was large, soft, and yellow; it weighed 56 oz., and gave a specific 
gravity of 7 J. The spleen was soft, somewhat enlarged, and moderately 
congested. Kidneys. — Both were slightly congested. There was no 
urine in the bladder. 

Observation. — Black vomit in stomach, and black matter throughout 
the intestines. 

No. 19. Female; aged 20(?). External Surface. — The body was well 
developed and muscular. The surface was quite warm, and but slightly 
yellow. The thorax, abdomen, neck, parts of the arms, and face were 
covered with prominent very dark purplish veins. The cuticle peeled 
off readily everywhere, giving manifest signs of advanced decomposition. 
The examination was made 16 hours after death. 

Cranial Cavity. — This cavity was not examined. 



ILLUSTRATIVE CASES. 329 

Thoracic Cavity. Lungs. — These organs appeared to have been 
congested, but they were both much decomposed throughout the entire 
pulmonic structure. Heart. — The muscular structure of the heart was 
quite soft, and the fingers passed easily through its entire substance on 
the slightest pressure. There appeared to have been some amount of fatty 
degeneration in the right ventricle, but owing to the advanced state of 
decomposition and almost dissolution (histolysis) of the tissues, it was 
impossible to determine the precise condition. 

Abdominal Cavity. — The intestines generally were much distended 
with gas, and presented a general bluish green discoloration intermixed 
with patches of a reddish and purplish color. Stomach. — The stomach 
was filled with a dark bloody fluid ; the gastric mucous membrane was 
extensively decomposed, softened, and converted into a dirty blackish 
slime. The intestines, especially the ileum and colon, were filled with 
a dark olive-green decomposed fluid. 

Liver.- — The liver was soft, of a general brownish color, interspersed 
with yellowish spots here and there. The hepatic structure was com- 
pletely disorganized, softened, and decomposed ; its specific gravity was 
8 \. Kidneys. — The kidneys had been congested ; they were in an 
advanced state of decomposition, softened, and disintegrated. 

Observations. — This patient was but four or five days in hospital. He 
had presented the usual symptoms, black vomit with hemorrhage from 
the nose and mouth. 

The temperature of the weather was not unusually elevated, and other 
cases examined on the same day under the same conditions, and at least 
as long after death, presented no unusual amount of decomposition. 
The decomposition in this case was as advanced and as rapid as in some 
of those described by me in the (Blue Book) Report on the Pathology 
of the Diseases of the Army in the Crimea. 

No. 20. Female ; aged 62. External Surface. — The body was well 
developed, and very fat : the muscular masses well contracted came 
prominently into view in the arms and thighs. The conjunctivas were 
yellow, as also the surface generally. Purpuric spots were observable 
everywhere, but most marked on the breast and arms. The hands and 
feet were contracted, and the latter inverted, with the toes pointed. 
Dark bloody fluid flowed from the mouth when pressure was made with 
the hand upon the epigastrium. 

Cranial Cavity. — Some dark bloody serum was effused on the dura 
mater, which likewise presented some arborescence. There was consi- 
derable sub-arachnoid effusion, with 2 ounces of bloody serum at the 
basis cranii. There was great engorgement of the sinuses ; there was 
extensive arborescent injection of the pia mater, with bloody effusion 
upon the surface of the right hemisphere in two situations. The cere- 
bral substance was but slightly sable on section. The ventricles con- 
tained a few drachms of bloody serum. The velum interposituni'was 
slightly congested. The cerebellum was somewhat congested and 
softened. 

Thoracic Cavity. Lungs. — The lungs were congested posteriorly. 
Heart. — The right ventricle was distended to two volumes, and the 
whole heart had assumed a great transverse width. There were some 



330 PATHOLOGICAL ANATOMY OF YELLOW FEVEE. 

few shreds of coagula in both ventricles, with fluid black blood. The 
valves and aorta were remarkably yellow. 

Abdominal Cavity. Stomach and Duodenum. — Both these organs 
presented an intense general dark red injection, lees of wine coloration. 
The gastric epithelium was perfect ; the lenticular glands of the stomach 
were here and there prominent above the surface as whitish spots. The 
stomach was filled with dark bloody fluid. The small intestines contained 
a similar fluid : they were much congested, as was likewise the colon. 
The mucous membrane was firm. 

Liver. — This organ was of a yellowish-brown color, chocolate-colored. 
Its specific gravity was T-J-. The spleen was slightly enlarged, but not 
otherwise altered. The kidneys* were congested. 

Observation. — This was an example of the algid form. The patient 
was only 5 days ill. On admission the surface was cold, the tongue 
cold, and the pulse obliterated. 

No. 21. Female; aged 65. External Surface. — The body was thin 
and somewhat emaciated. The conjunctivae were yellow, the surface 
generally was but slightly so. Bloody sordes were observable on the 
lips and teeth ; the hands and feet were contracted. 

Cranial Cavity. — The dura mater presented a yellowish coloration ; 
slight arborescent injection was observable on it. There was much sub- 
arachnoid effusion, and much gelatinous and opalescent serosity in the 
convolutions. There was slight general congestion of the right hemi- 
sphere, and general but slight injection of the pia mater. The cerebral 
substance was but slightly sable, and there was but little serum in the 
ventricles ; no abnormal change in cerebellum. 

Thoracic Cavity. Lungs.. — Both were congested and adherent through- 
out to the parietes. Heart. — There was a blackish hemorrhagic patch 
on the posterior surface of the apex of the left ventricle ; the organ was 
of normal size, and was thinly covered with an external deposit of fat. 
The cavities contained but little blood ; marked yellow coloration of the 
valves and aorta was observed. The blood which escaped from the 
great vessels on section was very black. 

Abdominal Cavity. — General congestion of the intestines was observ- 
able. Stomach. — The stomach presented the hour-glass contraction, 
the gastric surface presented patches of congestion here and there, with 
large arborescent veins at the great curvature. The ileum exhibited 
bright pink coloration, and contained much blackish bloody fluid. The 
colon was congested in its upper two-thirds, and contained clay-colored 
fecal matter. Liver. — The liver was very yellow, slightly diminished in 
volume ; its specific gravity was '7. The gall-bladder contained about 
1^ ounces of dark greenish bile. The spleen was small and contracted. 
The kidneys were small, yellowish, and the cortical part manifestly fatty. 

Observations. — Yellowish coloration of dura mater observable. 

Bright pink coloration of ileum, with much blackish fluid blood effused 
on mucous surface of this intestine. 

No. 22. Male; aged 18. External Surface. — The surface was yel- 
low, and not otherwise remarkable. 

Cranial Cavity. — Slight yellow coloration was observable in the dura 
mater, which also presented some arborescent vascularity. There was 



ILLUSTEATIVE CASES. 331 

much sub-arachnoid effusion. The posterior parts of the hemispheres 
were congested. The cerebral substance was but slightly sable. The 
ventricles contained much serum. The spinal cord and its membranes 
were normal. 

Thoracic Cavity. Lungs. — The pulmonic substance was generally 
congested. Heart. — This organ was normal ; the valves were colored 
yellow, especially in the left ventricle, which contained a large yellow 
fibrinous coagulum. 

Abdominal Cavity. Stomach. — The gastric surface was injected here 
and there, and in parts eroded (post-mortem self-digestion). The sto- 
mach was filled with black matter, partly thick and clotted, partly fluid. 
The intestines were yellowish externally, but contained a large quantity 
of thickish, semi-fluid, black matter, altered blood. The mucous sur- 
face was firm and normal. 

Liver. — The liver was very yellow, its substance dry and hard; its 
specific gravity was 7$. The spleen was contracted and firm, but not 
otherwise altered. The kidneys were slightly congested. The bladder 
was full of straw-colored urine. 

Observations. — This case also presented slight yellow coloration of 
the dura mater. 

Intestines yellowish externally, but contained much semi-fluid black 
blood. 

No. 23. Male ; aged 40. External Surface. — The body was yellow. 

Cranial Cavity. — The dura mater was slightly yellow. There was 
but slight congestion of the surface of the brain. The cerebral sub- 
stance was normal, there was no fluid in the ventricles. The spinal 
canal presented nothing abnormal. 

Thoracic Cavity. Lungs. — The lungs were normal. Heart. — The 
organ was slightly hypertrophied, the valves in the right ventricle were 
yellow ; the cavities contained but little blood. 

Abdominal Cavity. Stomach. — This organ was yellowish externally, 
it contained gray semi-fluid matter, and its mucous surface was but 
slightly congested ; a similar grayish matter was found in the small in- 
testines ; there was likewise some blackish fecal matter. Liver. — The 
liver was very yellow, both on surface and on section ; its specific gra- 
vity was 8. The gall-bladder was distended, and contained about two 
drachms of dark green bile. The spleen was normal. The kidneys were 
slightly yellow. The bladder was contracted, and contained only a 
small quantity of yellow urine. 

Observation. — Yellow coloration of stomach observed externally. 

No. 24. Male; aged 34. External Surface. — The surface was yel- 
low, anteriorly, livid posteriorly. The body presented the external fea- 
tures of the disease in a well-marked manner. The muscular masses 
were prominent, especially the biceps in the arm, the recti and vasti in 
the thigh, and the gastrocnemii. 

The iris and conjunctivas were yellow, hemorrhage trickled from the 
mouth and nose. There were several blue-black patches on the back 
and sides. 

Cranial Cavity. — Yellow coloration was observable through the dura 
mater ; there was considerable sub-arachnoid effusion, and 2 oz. of 



332 PATHOLOGICAL ANATOMY OF YELLOW FEVEE. 

serum in the basis cranii ; the surface of the hemispheres was congested; 
the cerebral substance was only slightly sable, there was a small quan- 
tity of serum, 1 to 2 drachms in the ventricles. 

Thoracic Cavity. Lungs. — The lungs were congested posteriorly, 
but there was no general engorgement of the pulmonary substance. 
Heart. — About 1J oz. of yellowish serum was found in the pericardium. 
The right ventricle was distended with black fluid blood, the left ven- 
tricle was contracted, but contained some blackish fluid blood. The 
lining membrane of the heart was yellow, as were also the valves, and 
the muscular structure itself. 

Abdominal Cavity. Stomach.-— The walls of the organ were tinged 
of a dark crimson, with here and there patches of pink coloration ; it 
was filled with black fluid blood. The intestines throughout were filled 
with a blackish inky matter, altered blood. Liver. — The liver was of a 
general yellow color, with minute points of stellate vascularity distri- 
buted through it ; it was tinged of a greenish olive color on its under 
surface ; the gall-bladder contained 1 \ oz. of dark bile. The spleen was 
normal. The kidneys were congested and slightly yellow. The bladder 
was distended with straw-colored urine. 

Observations. — This case died on the 5th Jan. 1858. It presented 
all the characteristic symptoms of the disease in its sthenic form, and it 
is sufficient proof that, up to this date the cause of the disease was in 
active operation, though its propagative force was in abeyance. 

Yellow coloration of cardiac substance. 

Dark crimson color of parietes of stomach. 



SUPPLEMENTARY. 333 



CHAPTER XI. 

(SUPPLEMENTARY.) 

As bearing, amongst other tilings, on the very important ques- 
tions of the origin, local history, and meteorological relations of 
a well-recorded epidemic of yellow fever, I think it will be useful 
to append the following observations, which contain a summary 
of the chief climatological and other elements determined in 
connection with the Lisbon epidemic of 1857. It is chiefly 
extracted from my official Eeport to the Eight Honorable the 
President of the General Board of Health, London. 

I had the honor to present to the Board of Health a Eeport 
on the Pathology, Therapeutics, and General Aitiology of the 
Epidemic of Yellow Fever which prevailed in Lisbon during 
the latter half of the year 1857. 

As was therein explained, my mission to that city on the occa- 
sion in question was one voluntarily undertaken in the interests 
of science and humanity. But though my investigations had 
no official character, the reception which I met with in the Por- 
tuguese capital, and the facilities afforded me for the fullest 
prosecution of my inquiries, were such as to call for my warmest 
acknowledgments. 

In that document I took leave, in. the first place, publicly to 
tender my grateful thanks to his most faithful Majesty Dom 
Pedro V., for the many gracious courtesies shown to me at his 
Majesty's hands, and the cordial interest personally evinced by 
him in my labors. 

I had, in the next place, to acknowledge my obligations to his 
Excellency the Count de Sobral, civil governor of Lisbon, to the 
medical faculty generally, and to many leading persons of that 
city, for the facilities afforded me for carrying on my observations, 
and for the uniform courtesy and kindness which I experienced 
at all times during my sojourn in Portugal. 



334 YELLOW FEVEE OF LISBON. 

Iu the several parts and sections of the annexed Eeport, I 
entered very fully into the pathology of the epidemic, and into 
the climatological and other conditions supposed to be concerned 
in its causation. I also discussed the meteorology of the Portu- 
guese capital for such periods antecedent to the invasion of the 
epidemic as could be illustrated by reliable records. 

The very full details which I have furnished with regard to the 
clinical history and morbid anatomy of the disease (Op. cit. Part I., 
Sections I. and II.) place the nature of the epidemic beyond 
doubt. It will be at once recognized as a yellow fever of very 
fatal character. 

The descriptions I have given of the several markedly different 
forms under which the malady manifested itself will, I think, be 
read with interest. And perhaps the details I have entered into 
on this head, and in the section devoted to pathological anatomy, 
will be found not devoid of practical importance. They indicate 
to us how the various conflicting accounts given by different 
writers, of yellow fever epidemics in different times and places, 
may be reconciled on the supposition that in one epidemic visita- 
tion one form of the malady was predominant, while, in another 
outbreak, the clinical characters presented were those of a far 
other type of the disease. Nothing almost in disease can be 
apparently more distinct from its congener in the nosological 
category, than the " algid" from the " sthenic" or " hemorrhagic" 
variety of yellow fever as presented in the late Lisbon epidemic. 
However, in closely analyzing the essential phenomena of the 
several forms of the disease, we find they are but varieties de- 
rived from a common stock. 

The first great question which naturally presents itself in con- 
sidering an epidemic such as that, the history of which we had 
to examine, refers to its manner of origin and its mode of propa- 
gation. 

From the first invasion of the epidemic in Lisbon, a belief 
became wide spread and general that the disease had been im- 
ported. This opinion, it is necessary to add, was not confined to 
any class of the community. It was shared alike by persons in 
all ranks of society, by many amongst the educated as well as the 
illiterate, and by many highly respectable members of the medi- 
cal faculty, as well as by the public at large. This opinion, 
though so generally diffused, was not, however, universally ac- 



ORIGIN OF EPIDEMIC. 335 

cepted, for both in the faculty of medicine and from several non- 
professional persons of great intelligence; I have heard the most 
distinct avowals of a belief in the entirely local origin of the 
epidemic, while certain existing conditions were pointed to as 
manifestly sufficient to account for its causation. As an impartial 
investigator, I considered it to be my duty to inquire very fully 
into such evidence as was adduced in support of both sides of this 
important question. 

After most careful inquiry amongst various official persons, 
and in all quarters in which reliable evidence could be expected 
in such matters, I am obliged to state that in no one instance did 
I obtain such a consistent assemblage of facts, or such an array 
of well-supported allegations, as would, in my mind, warrant the 
conclusion that the importation theory was even moderately well 
founded. On the contrary, so vague, and in some essential par- 
ticulars so conflicting, were the allegations as to the time, place, 
and other circumstances attending the reputed importation of the 
disease, that I do not believe that the popular opinion so gene- 
rally held, as to the importation of the epidemic, admits of 
being reduced to anything like a uniform or consistent statement 
in writing. 

Of the reports in circulation as to the alleged importation, the 
two most generally received were, firstly, that the disease was 
communicated to persons in the Custom-house engaged in the 
examination of the baggage and personal effects of passengers 
arriving from the Brazils; secondly, that the manner of importa- 
tion was by certain cargoes of hides from the Brazils. In con- 
nection with the first report, it is to be observed that there was 
no uniformity in the accounts given by different persons of the 
circumstances of time and place under which the importation was 
alleged to have occurred. There was no concurrence of testimony 
as to the particular ship, the date of her arrival, the port she 
sailed from, or the health of the passengers she brought. By one 
set of persons the ship specified was the Brazilian mail steamer 
"Tamar;" by others a different ship was particularized with equal 
confidence. 

In one account of the importation of the disease in connection 
with hides from the Brazils, it was stated that the hides wore 
landed at the custom-house ; in another, that the hides were lauded 
at a certain wharf higher up the river. 



336 YELLOW FEVER OF LISBON. 

After the most careful inquiry in all quarters, I am unable 
to produce any more circumstantial account of the alleged 
importation of the malady than is contained in the foregoing 
statements. 

The considerable number of attacks and deaths which took 
place in the custom-house and in the adjacent parts of the city, 
was constantly adduced in proof of the origin of the epidemic in 
the custom-house, and its propagation from that establishment as 
a centre. As was, sufficiently shown, however, no such argument 
was supported by the facts proved. The undoubted frequency 
of the attacks, and the mortality in the quarter in question, were 
equalled and surpassed in districts considerably removed from 
proximity to the river. (See Prods Verbal, No. 1. Appendix 
No. vi. op. cit. p. 120.) 

The following is a summary of the chief circumstances which 
I found could be established on questionable authority as to the 
times and places of, and the other particulars attending, the out- 
break of the disease. 

1. It was proved beyond possibility of doubt, that true yellow 
fever, of a malignant and fatal character, prevailed both in Lis- 
bon and Oporto during the year 1856. (See op. cit. Appendix, 
No. 5.) 

2. Of 311 cases recorded to have occurred in Lisbon in 1856, 
somewhat more than two-thirds were observed in the districts St. 
Roque and Bica, far removed from the river margin. 

3. The three districts attacked in 1856, Belem, St. Eoque, and 
los Anjos (Bica), are widely separated from each other, and pre- 
sent no recognizable connection, commercial or otherwise, amongst 
themselves (see map of Lisbon) nor with the exterior by way of 
sea traffic. These districts are likewise on different elevations ; 
one, that of St. Roque, being some 100 to 150 feet above the 
Tagus level. 

4. The yellow fever of Oporto (1856) is attributed by Dr. Gon- 
veia Ozorio of that city to the filth of the quarter Miragaia, in 
which the disease prevailed, and not to importation. 

5. While in general the parts of the city chiefly attacked in 
the Lisbon epidemic of 1857 were the thickly inhabited districts 
in the flat of the town bordering the river, it is undoubted that 
ravages equally great, if not more severe, were committed in cer- 
tain districts having more or less elevation above the Tagus. 



LOCAL CONDITIONS. 661 

6. The districts of the Mouraria, Alfama, St. Roque, and St. 
Catherine, which were greatly scourged by the epidemic, are on 
various elevations, and are more or less separated from the flat 
of the city and the river margin. 

7. While there was no uniform testimony as to the time, place, 
and other circumstances of the alleged importation of the epi- 
demic in 1856 and 1857, it is certain that no case of the disease 
was received into the Lazaretto in either of those years, or in any 
recent year. (See op. cit. Appendix 6, pp. 15 and 22, where it 
stated as follows : " The inspector of the Lazaretto, who has re- 
sided there 42 years, affirmed in the most positive manner that 
there has never been one single person of those undergoing 
quarantine, who was attacked with an epidemic disease.") 

8. All the parts of the city largely attacked by the epidemic, 
presented in common certain conditions of insalubrity, which 
may be classed as follows : — 

A. Defective water supply. 

B. Total absence of, or more commoDly, extremely deficient 

sewerage. 

C. Total absence or incompleteness of house-drains, privies, 

and a consequently unclean state of the streets. 

D. Badly-constructed dwellings, with deficiency of light and 

air, and want of thorough ventilation. 

E. Absence or defective condition of tertiary and secondary 

sewers ; when present, such sewers, as well as those of the 
largest section, were proved by repeated inspection on the 
part of the Fourth Commission of the Sanitary Congress, 
and by my own personal observation on several occasions, 
to be in great part wholly ineffective, being choked with 
soil, sand, or rubbish, and giving exit at their main em- 
bouchures on the Tagus either to little or no fluid or solid 
material, or to only a small quantity of clear and almost 
pure water. (For details, see op. cit. Proch Verbal, No. 
1, and Proces Verbal, No. 2, of Visits of Inspection of 
Fourth Commission. Appendix 6, pp. 119 and 120.) 

9. The state of the shore of the Tagus, for fully one-half of the 
extent of the city along the river side, was such as to be a highly 
effective cause of insalubrity, not only to the adjacent districts, 
but to the whole capital. The vast area of extremely fetid de- 

22 



338 YELLOW FEYER OF LISBON. 

composing mud left exposed at low water, exhaled noxious gases 
very prejudicial to health. 

10. It is to be observed, that notwithstanding the free commu- 
nication between the shipping in the Tagus and the shore, and 
between the city and the adjacent districts in the immediate 
vicinity, and at more remote distances, to which many thousands 
of the inhabitants (probably 30,000) withdrew, there was no evi- 
dence whatever of the disease having been conveyed to the 
shipping or the interior. 

The freest communication was kept up, even during the height 
of the epidemic, between Lisbon and Cintra, and many other 
favorite places of resort to which the citizens retired in great 
numbers; yet no cases can be adduced to show that the disease 
spread, or was carried by contagion or otherwise from Lisbon to 
such localities. Cintra was, perhaps, the place most frequented, 
and with which much free daily communication was consequently 
kept up ; but I could obtain no reliable evidence that one single 
case of genuine yellow r fever occurred in that town. 

I have heard statements to the effect that the disease was pro- 
pagated by contagion to some minor towns, but I have seen no 
evidence, documentary or otherwise, to prove the truth of such 
allegations, or render them even probable. On the contrary, the 
uniform testimony of popular report (so far as it is at all reliable 
or worth noticing), went to show that the disease was not pro- 
pagated beyond the walls of Lisbon. 

In a very few instances I have heard evidence, which seems to 
be not unworthy of confidence, that persons long resident in Lis- 
bon, and exposed to the causes of the disease, manifested its cha- 
racteristic symptoms only on reaching some locality more or less 
distant to which business called them. But I know of no single 
case in which the disease was propagated to other persons resident 
in such locality outside Lisbon. Nor indeed have I ever heard 
it confidently alleged by the most warm advocates of contagion, 
that such propagation of the disease took place out of Lisbon. 

It is worthy of remark in connection with this subject, that 
while opinion was so strongly in favor of the importation theory, 
little if any apprehension of personal contagion was entertained 
by those in attendance upon, and in daily contact w T ith the sick ; 
and this indifference to exposure to the supposed contagion of 
the fever was observable in all classes of society, amongst the 



MOKAL COURAGE OF POPULATION. 339 

lowest as well as the highest. The effects of such moral courage 
were most beneficially felt by those amongst the poor and friend- 
less who became victims of the disease. A large number of the 
inhabitants, it cannot be denied (variously estimated at 30,000 to 
40,000), sought safety for themselves and their families by a pre- 
cipitate flight from the foci of infection ; and the closed doors, 
abandoned houses, and the suspension of the hum of business in 
whole streets of the most active centres of commerce, realized to 
the spectator all the most striking features of a plague-stricken 
city. Nevertheless, amongst the population which remained, 
humanity was spared those humiliating and appalling scenes, 
which the medical historian tells us were so constantly presented 
in the epidemics of the middle ages, of the sick and the dying 
abandoned by their nearest relations and friends. So far from 
this being the case, it must be stated, and no higher eulogium 
could be passed on the people of any city, that during the late 
Portuguese epidemic devoted attention to the sick was the uni- 
versal rule with all classes of society ; and even on the friendless 
and the stranger I have seen all the care and anxious solicitude 
bestowed that could be lavished on the nearest and the dearest 
friend or relation. 

I have elsewhere remarked on the excellent tranquillizing 
effect produced on the public mind by the truthful and highly 
creditable manner in which the daily bulletins, giving a statement 
of the progress of the epidemic, were published by the authori- 
ties. The worst was at all times known, and exaggerated fears 
rendered impossible ; and I have no doubt that but for these re- 
turns the panic and consequent exodus from the city would have 
been far more considerable than they were. 

It is interesting to remark the very similar results of observa- 
tions made by competent authorities with regard to the Lisbon 
epidemic of yellow fever, in 1723. Dr. Gilbert Kennedy says : 
" The high parts (of the city) are much freer than the low parts, 
and the villages and country houses about town are entirely free 
from this distemper, notwithstanding the great communication." 
(See Op. cit. Appendix No. 3, for letter of Dr. Gilbert Kennedy 
to Her Britannic Majesty's Consul at Lisbon, under date October 
31, 1723.) The observations made in 1723, with respect to the 
unclean state of certain parts of the city, will be found to apply 
equally well to the condition of things in many localities in the 



34:0 YELLOW FEVER OE LISBON. 

present day. (See Op. cit. Appendix No. 2.) I must refer to 
Part III. of the Parliamentary Eeport for dull details on the 
special topography, physical history, and other particulars of 
Lisbon required for the elucidation of the rise and progress of 
the epidemic. I shall here content myself with the statement, 
which will be found borne out by the evidence adduced, that 
where most palpable causes of insalubrity prevailed, there were 
the most fatal ravages of the epidemic witnessed. In the forcible 
and graphic terms of one of the historians of the epidemic of 
1723, Dr. Manoel da Silva Leitao, { most deaths where most dirt.' 
(See Op. cit. Appendix No. 2.) 

It has always been found difficult to fix with certainty the 
precise date of occurrence and the locality of the first cases of 
any epidemic visitation. It cannot be doubted that while in the 
epidemic of 1856 two out of the three localities chiefly attacked, 
St. Koque and Bica, were at some distance from the river ; in 
1857 the most considerable number of cases occurred, in the first 
instance, in the proximity of the Custom-house, and in that es- 
tablishment itself. 

No case is recorded in this locality prior to September, 1857 ; 
but before this date there seems good ground for believing 
that cases of undoubted yellow fever had been observed. One 
case is recorded as having been verified (by Dr. Arante) so early 
as May, 1857. Another case is stated to have been seen in July, 
while there appear to have been at least five in August. Some 
of these cases occurred in the quarter of St. Eoque, an elevated 
district 100 to 150 feet above the Tagus level, as already indi- 
cated. It has been attempted to give a special significance to 
certain of these cases, by saying that the parties attacked, though 
residents in the District of St. Koque, were employed in the Cus- 
tom-house. I can neither affirm nor positively deny the truth of 
this statement, as I could procure no reliable evidence respecting 
it, and I am not aware that any such exists. My own conviction, 
based on the results of inquiries made amongst medical men of 
all shades of opinion, is, that prior to the declared and fully re- 
cognized existence of the epidemic, isolated cases presented them- 
selves in various parts of the city, of which no accurate record 
was made, but of the existence of which no moral doubt can be 
entertained; it is not admissible of course to rely exclusively on 
such cases. 



EXTENT AND MORTALITY OF EPIDEMIC. 



341 



The total Dumber of persons attacked may be estimated at 
between 16,000 and 17,000, and the total deaths at about 5,500. 
(See Op. cit. Part II.) 

In the absence of strictly reliable statistics, and I found it en- 
tirely impossible to obtain any such, a comparison of the attacks 
and deaths in various localities could not be accurately made. 
If, however, we assume the following data (taken from the only 
figures now at my disposal) to be approximately correct, we may 
obtain the percentages of attacked and deaths in given numbers 
of the population in certain localities, and likewise the percentage 
of deaths to attacks. 

The accompanying figures exhibit the numbers of persons 
employed, with the number of attacks and deaths, and the per- 
centages of both, and of the latter to the former (deaths to attacks), 
in the several localities specified. The figures taken for the cus- 
tom-house are the highest I find in any return from that establish- 
ment. I have appended for comparison the statistical elements of 
some few other epidemics. 





CO 


«H 




S^v 


O to 


o 




© § 


O 


o 


&o,3 ? 


MSB 


60 2 




u^ 


Sh CO 


<3 «j 


2t 2 S-3 


*2 s'i 


i? "3 cd 




M> 


2^ 


^s 


§1-2 * 


a v' a '> 


S c ° 




££ 


S ^ 


si 


S c3 g;g 


S^i S;g 


p r d _rf 






|- 


r-l <0 


|-oS.a 


S'oS.2 


S'o^ 


In Lisbon Epidemic, 1857. 














Custom-house 


542 


121 


49 


22.324 


9.040 


40.495 


Royal Marine Arsenal . . 


1,125 


291 


113 


18.755 


10.044 


38.831 


House No. 55, Rua do Arsenal 


52 


42 


16 


80.769 


30.769 


38.142 


Desterro Hospital .... 




2,525 


972 






38.491 


Garrison of Lisbon (approxi- 














mately) 


4,300 


622 


118 


14.465 


2.744 


18.971 


Population of Lisbon 1 ex- 














posed 


200,000 


17,000 


5,500 


8.050 


2.750 


32.352 


In other Epidemics. 














Population of Cadiz . . . 


72,000 


48,000 


5,000 


Q6M6 


6.944 10.406 


Population of New Orleans 












exposed (epidemics of 












1853) 


125,000 


29,020 


8,101 


27.910 


6.480 21.023 


Population of 25 Spanish 












towns and cities attacked 












in 1804 


427,228 




52,559 




12.601 10.000 


Population of Rio de Janeiro 












(Epidemics of 1851 to 1854) 




100,000 


10,000 


10.000 






Aggregate of exposed popula- 














tion of Vicksburg, Provi- 














dence, Jackson, U. S. . . 


4,090 


2,780 


777 


67.970 


18.997 27.956 



1 According to Franzini's estimate, and deducting 30,000 for probable number 
of inhabitants who left the city during the epidemic. 



342 YELLOW FEVER OF LISBON". 

In glancing at this summary as it concerns the Lisbon epidemic, 
we are struck with the absence of any near coincidence in the 
results, except in the percentage of deaths to attacks, which, if 
we omit that of the garrison of Lisbon, shows a sufficiently close 
uniformity throughout. 

These figures, if strictly accurate, would show a considerable 
power of resistance to epidemic invasion amongst the troops of 
the Lisbon garrison, and also a far lower rate of mortality to 
attacks than in any of the classes of individuals here specified or 
in the population at large, but the liability to attack amongst the 
troops in garrison is nearly twice as great as that amongst the 
population at large. 

The percentage of attacks to individuals, and of deaths to 
attacks, was, it will be observed, very high amongst those em- 
ployed in the custom-house; the similar percentages amongst 
those engaged in the Royal Marine Arsenal were below those of 
the custom-house population, but still considerably above those 
of the population at large. It will be seen, however, that by far 
the highest percentage of attacks to individuals (80.769 per cent.) 
was exhibited by the inhabitants of the house No. 55, Eua do 
Arsenal. This house, of large proportions, forms the corner of 
Largo do Pelourinho and of the Rua do Arsenal ; though of great 
size, it was evidently vastly overcrowded, and could not from its 
position have been at all adequately ventilated. The condition 
of the sewage of this locality may be judged of by perusing the 
Prods Verbal of the visit of inspection of the Fourth Commission 
to the Royal Marine Arsenal, within the precincts of which the 
great sewers of this locality open on the Tagus. (See Op. cit. 
Appendix, No. YI. Prods Verbal, No. 3, p. 120.) The commis- 
sion states: " The large sewer has 3m. 20c. (about 10 feet 6 inches) 
in height, by 2m. 15c. (about 7 feet) in width. It had been re- 
cently obstructed with mud derived from the basin, and with 
sand, and by a boat which had been driven in by the force of the 
sea on the occasion of a tempest. At present it is free as far as 
the Rua direita do Arsenal. Its mouth was stopped in such a 
way as to prevent the mud of the basin from entering, but to 
allow of the water flowing out from within ; this (the water) is 
perfectly limpid, and according to the statement of the inspector 
(of the Arsenal) has for three years presented the same color." 
This sewer, it is to be remembered, is intended to serve a con- 



MOETALITY OF YELLOW FEVER IN EPIDEMICS. 646 

siderable portion of the city, including the Largo do Pelourinho, 
the Rua do Arsenal, and, of course, the house No. 55 in question, 
the state of salubrity of which may be judged of from the imper- 
fect performance of its functions by the sewer just described. 
This is by no means an isolated example of the manner in which 
the epidemic fever exhibited its virulence in an especial manner, 
in particular localities and particular houses. The spacious man- 
sion of an eminent mercantile family was pointed out to me in 
the place opposite the Cathedral, in which as many as twelve 
members of the same family, including domestics, were attacked, 
of whom three died. The first of these cases was seen on Sep- 
tember 1st. These data were furnished to me by the physician 
who attended the family. In another family in the parish of St. 
Catherine, six were attacked, of whom four died. 



Ratio of Mortality from Yellow Fever in Various Epidemics} 



Epidemic of 


Date. 


In population 
exposed. 


ii 


population 
attacked. 


Philadelphia .... 


1793 


linlO 






a 








1797 


1 in 16.6 






it 










1798 


lin 6 






u 










1793,1797,1798 


1 in 10.13 






a 










1805 




1 


in 3.86 


a 










1819 




1 


in 1.2 


u 










1793—1819 




1 


in 2.12 


ft 










1853 




1 


in 8.328 


New York (average) 










1 


in 2 


Baltimore (average) 










i 


in 2.87 


Charlestown (average) 










1 


in 4 


New Orleans . 






1853 


lin 15.43 


1 


in 3.58 


Vicksburg 






1853 


lin 6 


1 


in 4.42 


Providence . 






1853 


lin 2.424 


1 


in 2 


Jackson (Mississippi) 






1853 


lin 6.160 


1 


in 3.125 


Mobile . 






1853 


lin 15.113 






Windward and Leeward 


Commanc 


L 










(average) . 










1 


in 2.33 


Jamaica Command 










1 


in 1.33 


Rio de Janeiro 










1 


in 10 


Spain (averages of 25 towns attacked) 


J 1804 extremes 


(1 in 2.25 
\ lin 13.3 


1 
1 


in 1.3 
in 6.42 




1 1804 mean 


1 in 6.42 


1 


in 3.087 


Cadiz ...... 


1804 


lin 1.5 


1 


in 9.6 


Gibraltar ..... 


1829 




1 


in 1.66 


Lisbon ...... 


1857 


1 in 36.363 


1 


in 3.09 



1 For the American epidemics, the authorities are La Roche, Barton, and Lal- 
lemant ; for the West Indian and other commands, Sir A. TuUoch's and the 
Navy Medical Reports. 



344 YELLOW FEVER OF LISBON. 

The above summary will enable us to compare the ratios of 
mortality in the Lisbon epidemic with those in other remarkable 
epidemics. The ratios are calculated for the mortality to the 
population remaining in the cities and towns attacked, so far as 
could be ascertained with any approach to accuracy; also for 
deaths to attacks. 

It will be at once observed, that while there is a certain amount 
of general coincidence in the latter ratios, as those of deaths to 
attacks, the widest difference prevails between the ratios of deaths 
to population exposed. In this last-named respect, the Lisbon 
epidemic of 1857 is shown to have been a much less direful 
scourge to the population than any other of those with which it 
is compared. The maximum of deaths to population exposed, 
1 in 2 J, is that in the losses of the Spanish epidemic of 1804; 
the minimum, 1 in 36J, that in the Lisbon epidemic of 1857. 

The next class of questions to be considered refers to the 
meteorological conditions supposed to be favorable to the induc- 
tion of epidemic disease. 

From the records of the Eoyal Observatory of the Infant Dom 
Luiz, I was enabled, through the kindness of the Director, Senhor 
Pegado, to present very full details of the climatology of Lisbon 
for the years 1855, 1856, 1857. I owe to the same source the 
excellent graphic representations of the meteorological elements 
for the year 1857, and their relation to the rise and progress of 
the epidemic, which is furnished by Chart 3, Op. cit. The records 
of this Observatory do not, however, extend sufficiently far back 
to furnish us with a series of means available for the purposes of 
comparison. "We have, therefore, to fall back on the records of 
private observers, amongst whom must be specially named Colonel 
Franzini and Dr. John Martin, the latter an English medical 
practitioner of long standing, and of good repute in Lisbon. 
To both these gentlemen I am indebted for meteorological 
returns, extending over a considerable period of years. The 
observations of Dr. Martin are of especial interest, as they have 
been made at nearly the level and within the districts most sub- 
ject to the epidemic influences. To the zeal and industry of Dr. 
Martin I owe two of the most valuable of the meteorological 
charts which accompany this Eeport, which he had the goodness 
to draw up at my request. 

As I have in Part III. of my official Eeport entered very fully 



METEOROLOGICAL CONDITIONS. 



345 



into the consideration of the meteorology of Lisbon for the year 
1857, and compared the meteorological elements of the epidemic 
months of that year with the similar elements of former years, so 
far as could be done with the data available, I must refer for full 
details on this important branch of the subject to the various 
sections of that work. I will only briefly remark here, that so 
far as the available data can be relied on, there is no evidence of 
any very unusual atmospheric disturbances having preceded the 
outbreak of the epidemic; nor again, during the months in which 
the epidemic reigned, is there to be recognized any very extra- 
ordinary departure from the meteorological conditions of the 
same months in former years. 

The following summary contains a brief view of the most 
important results of the discussion of the climatology of Lisbon 
for 1857, as compared with preceding years. 

Until a long series of observations shall have been accumu- 
lated, there does not appear to be any method of arriving at a 
mean of the monthly barometric pressure for Lisbon, based on 
sufficiently extended observations and reliable for the purposes 
of comparison. The monthly means for 1855, 1856, 1857, as 
recorded in the Eoyal Observatory, fail to show any very re- 
markable disturbances for 1857. The means for March, May, 
June, and August, are lower than the corresponding ones for 
both 1855 and 1856. The means for 1857 are greater than those 
of 1855 only in the months of February, October, November, 
and December; they are less in the other months. They are 
greater than those of 1856 in January, April, July, September, 
and December, and less in the remaining months. 

The discussion of the thermometric elements for 1857 may be 
summed up as follows : — 

Difference in 1857 from Mean of 16 years. 
Franzini. (Centigrade scale.) 



January. 


February. 


March. 


April. 


May. 


Juue. 


—.782 


1.193 


—.805 


— .9S3 


—1.61 


—.638 



July. 


August. 


September. 


October. 


November. 


December. 


4-1.802 


4.86S 


4.325 


—.20S 


4.9S2 


—.791 



346 YELLOW FEVER OF LISBON. 

As I have elsewhere more fully considered, it will be found, I 
think, that there is good reason for supposing that the observa- 
tions of the Koyal Observatory, in consequence of its distance 
from the thickly inhabited parts of the city, and its superior ele- 
vation, do not accurately represent the meteorological elements 
of Lisbon proper. In discussing this subject, I have called 
attention to the great want of subsidiary stations for meteoro- 
logical observations in close proximity to the Tagus. I make no 
doubt that ere long this want will be filled by the same enlight- 
ened patronage on the part of His Majesty Dom Pedro V., which 
has already so much encouraged and advanced the scientific 
institutions of Portugal. 

The rain-fall for 1855, 1856, and 1857 appears to have exceeded 
the average of 16 years, as deduced from Pranzini's observations, 
extended for the data of this element over 23 years. According 
to this average, the mean rain-fall at Lisbon may be regarded as 
23 inches, while that of 1856 and 1857 was more that 34 and 32 
inches respectively. In the number of rainy days there is like- 
wise a marked difference ; thus the mean number of rainy days 
is given as 98, while in 1855, 1856, and 1857 it rained 171, 165, 
and 162 days respectively. 

It is to be observed that the three years, 1855, 1856, 1857, 
present an extraordinary increase of rain- fall, and in a sort of 
descending scale from 1855. The average rain-fall at Lisbon (as 
above stated) is generally assumed as 23 inches (nearly). In 
1855 the total rain-fall for the year was over 41 inches; in 1856 
it was more than 34 inches; and in 1857 it was still over 32 
inches, or about 9 inches above the average. By reference to 
Table A., pp. 77, 78, Op. cit., it will be found that the highest 
total rain- fall at Lisbon (on record) amounts to 44 T 1 o inches, being 
that of the remarkable year 1785, in which rain fell on 239 days. 
It may also be observed, and it is a circumstance of much inte- 
rest, that this large amount (that of 1785) was gradually reached 
as it were, there having been a progressive increase in the total 
annual rain-fall from 1783 ; and as after 1855 the total rain-fall 
was not reduced to the average in the succeeding year, but ap- 
pears to have decreased gradually, does there exist at Lisbon a 
rain cycle, gradually advancing from year to year to a maximum, 
and then gradually falling to an average, or perhaps to a mini- 
mum ? One year is recorded with only 10J inches of rain. It 



MONTHLY MEANS OF DEW-POINT, ETC. 



347 



may be that a succession of rainy years gradually influences the 
constitution of the population, till, with other concurrent causes, 
a climax of complicated morbid elements is brought about, which 
leads to the outbreak of epidemic disease. (For more full details 
see Op. cit. Part III. pp. 77, 78, 93.) 

The following Abstract shows the more important results of 
the Tables referring to the Dew-point, &c. (Op. cit. Part III. pp. 
95, 96, 97), compared by the means for the epidemic months, 
July to December inclusive, and for the years 1854, 1855, 1856, 
and 1857. 

Means. 





July. 


August. 


September. 




Dew- 
point. 


Elastic 
force of 
vapor. 


Vapor in 

cubic foot 

of air. 


Dew- 
point. 


Elastic 
force of 
vapor. 


Vapor in 

cubic foot 

of air. 


Dew- 
point. 


Elastic 
force of 
vapor. 


Vapor in 

cubic foot 

of air. 


1854 


59.90 


.535 


5.920 


60.75 


.553 


6.050 


60.75 


.557 


6.080 


1855 


59.75 


.529 


6.005 


60.75 


.568 


6.075 


58.10 


.504 


5.615 


1856 


59.00 


.514 


5.625 


59.00 


.373 


5.630 


56.85 


.328 


5.485 


1857 


60.25 


.540 


5.830 


59.20 


.525 


5.790 


60.50 


.534 


5.970 





October. 


November. 


December. 




Dew- 
point. 


Elastic 
force of 
vapor. 


Vapor in 

cubic foot 

of air. 


Dew- 
point. 


Elastic 
force of 
vapor. 


Vapor in 

cubic foot 

of air. 


Dew- 
point. 


Elastic 
force of 
vapor. 


Vapor in 

cubic foot 

of air. 


1854 
1855 
1856 
1857 


54.95 
55.05 
55.45 
54.10 


.466 
.472 
.306 
.457 


5.140 
5.265 
5.250 
5.080 


47.40 
45.15 
49.20 
54.50 


.371 
.342 

.258 
.456 


4.120 
3.855 
4.285 
5.110 


42.45 
46.15 
46.15 
50.00 


.308 
.349 
.354 
.411 


3.500 
3.980 
4.170 
4.620 



If we compare the means for 1854, 1855, and 1856, with those 
for 1857, we shall obtain the following results for 1857 : — 

July. — There was an elevation of the dew-point in July, when 
it reached a maximum, 60.25, as compared with 59.75 (1855). 
The elastic force of vapor, .540, was likewise at a maximum in 
the same month. The weight of vapor to the cubic foot of air 
was below the maximum in this month, as 5.83 (1857) is to 6.005 
(1855). 

August. — The dew-point in this month was above the minimum 
(59), but was below the maximum, as 59.2 (1857) is to 60.75 



348 YELLOW FEVER OF LISBON. 

(1854 and 1855). The elastic force of vapor was considerably 
above the minimum, .373 (1856), but below the recorded results, 
.553 (1854) and .568 (1855) respectively. The weight of vapor 
to the cubic foot of air was above the minimum, 5.63 (1856), but 
below the recorded results, 6.05 (1854), and 6.075 (1855). 

September. — The dew-point was higher than in the preceding 
years, having reached 60.5. The elastic force of vapor was above 
a minimum, .328 (1856), but below the maximum, .557 (1854). 
The weight of vapor to the cubic foot of air was below the maxi- 
mum, 6.08 (1854), but above that of the other years. 

October. — The dew-point was at a minimum, 54.1. The elastic 
force of vapor, .457, was above the minimum, .306 (1856), but 
below the results of the other years. The weight of vapor to the 
cubic foot of air was at a minimum, 5.08. 

November. — The dew-point was at a maximum, 54.5. The elastic 
force of vapor was likewise at a maximum, .456. The weight of 
vapor to the cubic foot of air was also in excess. 

December. — The dew-point, 50, elastic force of vapor .411, and 
the weight of vapor to the cubic foot of air, 4.62 were all in 
excess over the similar elements of the corresponding months in 
the previous years. 

It will be observed that in 1857 the clew-point fell but 10.25 
degrees from July to December. The minimum depression for 
the same period in the three preceding years was 12.85. 

The dew-point for November and December, it will be observed, 
was remarkably high, 54.5 and 50 as compared with 49.2 and 
46.15, the highest respectively in any of the preceding years. 
There is, however, no absolute relation between high dew-point 
and the epidemic outbreak in the preceding months. 

For more complete detail on the meteorology of the epidemic 
months, including the ozonometric and magnetic results, I refer 
to Part III. of the work already cited. The combined meteoro- 
logical and necrological tables at p. 81 et seq. of my Eeport, will be 
found to illustrate fully the daily meteorological elements, and the 
progress of the epidemic. The charts, giving a graphic or diagram- 
matic representation of the same elements, and their relation to 
the epidemic mortality, will also be consulted with interest. 

Finally, I wish it to be observed that here, as elsewhere, I pur- 
posely avoid specifying any one cause, or indeed any combination 
of causes, as that to which the origin of the Lisbon epidemic i3 



COMBINATION OF CAUSES. 6 IV 

to be directly traced. I have shown that there are no grounds 
to substantiate the theory of the importation of the disease from 
abroad, while there undoubtedly existed many causes, terrene as 
well as meteorological, which must be regarded as potent agencies 
for the origin and spread of epidemic disease. But I have held 
it in view, as my main purpose, to illustrate, by such reliable 
evidence as could be obtained, all the conditions, local as well as 
climatological, which existed at Lisbon, before and at the period 
of the outbreak of yellow fever, in the belief that by so doing I 
was best providing for the ultimate solution of some at least of 
the great questions of epidemiology, which will hardly admit of 
being scientifically approached till many histories of many epi- 
demics, with even more full details than I can offer on the present 
occasion, shall have been accumulated. 



INDEX 



Abdomen, symptoms referable to, in 
typhoid, 171 
tympanitis of, in typlius, 144 
Abortion of fever, fallacious theory as 

to, 76 
Abortive treatment of synocha, 76 
Abscess of the lung in typhoid pneu- 
monia, 138 
pericecal, in typhoid, 193 
Acetate of morphia, use and dangers of, 
in typhus, 119 
of potash, use of, in synocha, 79 
Acetum lyttse, use of, in typhus. 
Adhesions, conservative, lymphy, in pe- 
ritonitis, 213 
Affusion, cold, to the head, in synocha, 74 
Age, influence of, in determining mor- 
tality in typhus, 168 ' 
Aggregate glands, typhoid lesions of, 180 
Agminate glands, or patches of Peyer, 

typhoid affections of, 180 
Aitken, Dr. Wm., and Dr. Lyons on 
healing process in typhoid ulcers, 192 
Algid condition in typhus, 101 
Algid form of yellow fever, general ap- 
pearances in, diminution of tem- 
perature, lividity of surface, he- 
morrhages, &c, 252, 253 
striking case of, 254 
clinical history, 255 
pulse in, 256 
temperature in, 256 
Algid state in simple fever, 54 
Alimentation, impairment of, by parch- 
ment-like degeneration of mucous 
membrane, 180 
Ammonia, use of, in controlling delirious 

excitement in typhus, 118 
Angio-carditis considered by Bouillaud 

as cause of fever, 63 
Angiotenic fever (synocha), 58, et seq. 
Antimony, potassio-tartrate of, 76 
Antimonial powder, use of, in synocha, 

79 
Anxiete epigastrique, in cases of yellow 

fever, 258 
Aorta, abdominal, excited action of, as 
a sign of typhoid lesions, 217 



Aorta, local excited pulsation of, 126 
Aperients, saline, in synocha, 81 
Apparatus, glandular, of intestines, en- 
gaged in typhoid, 175 
Aqua ammonia acetatis, use of, in sy- 
nocha, 79 
Armies, prevalence and mortality from 

fever in, 22, 23 
Army, English, losses of, from fever in 
Crimea and at Scutari, 18 
French, losses of, from fever in Cri- 
mea, 18, 22 
on, with 
synocha, 75 
Arrowroot a suitable nutriment in ty- 
phus, 157 
Arteries, abdominal, undue action of, in 
typhoid, 173 
temporal, section of, in fever to be 
avoided, 74 
Astringents, 146 

acetate of lead, 146 
alum, 146 
chromic acid, 146 
gallic acid, 146 
ice, 146 

perchloride of iron, 146 
tannin, 146 
Astringents in typhoid, hemorrhages, 220 
acetate of lead, 220 
opium, 220 
tannin, 220 
gallic acid, 220 
perchloride of iron, 220 
chromic acid, 220 
Atrophy, glandular, of small intestines. 
201 
of intestinal mucous membranes, 
ISO 

Bad signs in typhus, 152 
Baglivi, his views referred to, 26 
Bancroft, views of, on yellow fever, -="1 
Barensprung, his researches on tempe- 
rature cited, 30 
Bark, use of, in typhus, 162 
Barre, coup de, in yellow fever, 250 



352 



INDEX. 



Becquerel and Breschet, researches on 

temperature cited, 32, 36 
Bed-sores, tendency to formation of, in 
typhus, 149 
upon the occiput, 
the ears. 

the last cervical vertebra. 
the inferior angles of scapula, 
the sacrum, 
the nates. 

the backs of the thighs, calves, 
heels, elbows, &c. 
pressure and position not the only 

causes of, 149 
forming cavities which burrow 

under skin, 149 
indicate use of stimulants liberally, 

150 
modes of treating, 150 
Bernard, his observations on sections of 

the sympathetic nerve cited, 36 
Black vomit in yellow fever, 257 
Bladder, case of enormous distension 
from retention of urine in typhus, 
159 
state of the, in typhus, 147 

over-distension of which urine 
dribbles away, 147 
Blair, Dr., on yellow fever, 291 
Bleeding in synocha, considerations re- 
specting, 65, 66, 67, 73 
Blisters to the head in synocha, 75 
Blood, affections of, in fever, 31 
Blue pill and colocynth in synocha, 81 
Boerhaave, his views referred to, 26 
Bonetus, his views referred to, 26 
Booley, case of, typhoid, 245 
Bouillaud, his views as to pathology of 

fever, 63 
Bowels, confined state of, causing cere- 
bral excitement in typhus, 117 
Brain fever, improperly so called, 63 

fever, so-called, 116 
Brandy, use of, in controlling delirious 

excitement in typhus, 118 
Breath, visible moisture on, in fever, 80 
peculiar odor of, in typhus, 101 
in yellow fever, 276 
Breschet and Becquerel, researches on 

temperature cited, 32, 36 
Bronchi, appearances, post mortem, 

after catarrh of typhus, 132 
Bronchial membrane, condition of, in 
typhoid, 197 
respiration and bronchophony sud- 
denly developed in typhoid 
pneumonia, 137 
Bronchitis in typhus, general characters 
of, 130 
•latency of this affection, 132 
capillary, 133 
Broncho-pneumonia of typhus, 138 



Brown-Sequard, his observations cited, 

36 
Bubonic swellings in typhus, 152 

resemblance of such cases to the 

plague, 152 
treatment of, 152 
Burgundy, use of, in typhus, 159 

Caecum, abscess around, perityphlitis, 
193 

Calaptesta, case of, typhoid, 237 

Calomel bolus occasionally required in 
synocha, 81 

Calor mordax, 60 

Calor praetor naturam of Gralen, 25, 29, 
30, 55 

Calor mordax in typhoid, 173 

Camphor, use of, in typhus, 165 

Camphor mixture, use of, 79 

as a means to allay thirst, 159 

Cantharides, use of the plaster and vine- 
gar of Spanish flies in typhus, 121 

Carrara water, use of, in synocha, 82 

Cases illustrative of typhoid fever, 227 

Catarrh of typhus, 131 

Celsus, his doctrine of inflammation, 41 

Census commissioners of Ireland on 
mortality from fever, 95 

Census commissioners of Ireland, their 
statistics of fever, 19, 20, 21 

Cephalalgia in yellow fever, 256 

Cerebral lesions of typhus, treatment of, 
117 

Cerebral lesions of typhus often fatal in 
upper classes, 113 

Cerebral symptoms in typhus without 
corresponding anatomical states, 116 

Cerebritis, or inflammation of the brain, 
simulated in typhus, 120 

Chalk and mercury in bronchitis of ty- 
phus, 135 

Chalybeates and tonics, use of, in the 
sequelae of relapsing fever, 94 

Cholera, Asiatic, condition of intestinal 
surface and glands in, 179 
typhoid states consequent on, 205 
typhoid, 204 
state of Peyer's patches in, 198 

Christison, definition of fever, 25 

Circulating apparatus, secondary le- 
sions of, in typhus fever, 124 

Circulation, state of, in algid cases of 
yellow fever, 260 
various states of, in fever, 74, 124 

Citrate of potash, use of, in synocha, 79 

Claret, use of, in typhus, 159 

Cleanliness and ventilation, value of, 
in treatment of typhoid, 167 

Clutterbuck, his views on fever, 63 

Coldness of extremities, tongue and 
breath, bad signs in typhus, 152 

Colitis, follicular, 198 



INDEX. 



Collapse in typhus, 115 

Collapse of pulmonary tissue in typhoid, 

196 
Collapse and sinking, tendency to, in 
typhus, and necessity of anticipating, 
162 
Colon, dysenteric process in sigmoid 
flexure of, 190 
glands of, participating in typhoid 

disease, 184 
typhoid lesion in, 192, 193 
Coloration of skin in typhus, 103, 107 
Coma in typhus after delirium ferox, 

115 
Congestion, stage of, in typhoid affec- 
tions of intestinal glands, 181 
Consolidation, typhoid of, lung, 195 
Contagion, question of, in typhus, 167 
Convalescence, partial, in typhoid fe- 
ver, 221 
Convulsions, Dr. Corrigan's case of, 

from retention of urine, 159 
Convulsions in relapsing fever, 90 
Corrigan, Dr., his form of fever bed, 150 
his case of convulsions from reten- 
tion of urine, 159 
Corry, case of, typhoid, 234 
Cough in bronchial affections of typhus 

very inconsiderable, 131 
Coup de barre in yellow fever, 250 
Counter-irritation to the chest in ty- 
phus, 134 
Counter-irritation to the head in syno- 

cha, 75 
Cramptom, Sir Philip, 123 
Cranium, typhoid lesions in, 194 
Crisis, 56 ; by sweat, by alvine or uri- 
nary secretion, 57 
more rare in fevers of present day 
than formerly, 67, 68 
Critical days, doctrine of, 69 
Cullen, his definition of fever, 25 
Cupping to the temples in typhus, dan- 
ger of, 118 
wet and dry, in cases of typhus 
bronchitis, 134 
Cusack, case of, typhoid, 228 
Cutaneous system, secondary lesions of, 

in typhus, 148 
Cutaneous surface, state of, in yellow 

fever, 259 
Cutis anserina, or goose-skin, 62 
Cutts, case of, typhoid, 240, 241 

Deafness occurring in course of typhus, 

154 
Death, period of its occurrence in ty- 
phus, 153 
presentiment of, in typhus patients, 
153 
Decubitus, dorsal, in typhus, 100 
De Haen on temperature, 29 

23 



Delirium, busy and threatening, in ty- 
phus, 119 
ferox of typhus, 115 
low muttering, in typhus, 113 
tremens of typhus, 114 
Depletion to be avoided in typhus 
bronchitis, 134 
local, with general stimulation, in 
typhus, 161 
Deposit, typhoid, duration of, without 
ulceration, 184 
typhoid, elimination of, without 
ulceration, 186 
Derivatives, value of, in treatment of 

typhoid, 216 
Dew-point, 347 
Diaphoretics in synocha, use and abuse 

of, 79 
Diarrhoea crapulosa, 72 

uncontrollable in typhoid, 217 
relation of, to typhoid ulceration, 

189 
with tormina, flatulence, &c, in 

synocha, 77 
with tympanitis in typhus, 144 
Digitalis, 36 

Dipsomaniac, analogy between state of, 
and that of delirium tremens of ty- 
phus patient, 118 
Diuretics in synocha, 81 

use and abuse of, in typhus, 202 
Douche, cold, danger of, in typhus, 118 
Dothionenterite, or typhoid fever, 169 
Draughts, carminative, in typhoid tym- 
panitis, 145 
Drinks in synochal fever, 82 
Dulness, tympanitic, in typhoid pneu- 
monia, 137 
Duodenum, state of, in cholera typhoid, 

205 
Dutertre, Pere, account of yellow fever, 

251 
Dysentery, association of, with typhoid 

lesions, 194 
Dyscrasis, choleraic, relation to t vphoid, 

208 
Dyspnoea in bronchial affections of ty- 
phus very inconsiderable, 131 

Eaton, case of typhoid, 234 

Effervescing mixtures, use of, in syno- 
cha, 82 

Effusion into bronchi in typhus, 136 

Effusion, pleuritic, in typhoid, 186, 190 

Eisenmann, his views as to a fever-stuff 
or pyretogen, 33 

Elimination of typhoid deposit without 
ulceration, 186 
by process of ulceration, 188 

Elimination through skin, kidneys, as 
in synocha, 77 

Emetics, employment of, 75, 76 



354 



INDEX. 



Emetics in synocha, 75 

Emetics, therapeutic uses of, various, 78 

Emplastrum lyttas, use of, in typhus, 

121 
Enemata, to promote sleep, 159 

use of, in typhoid tympanitis, 145 
Enteric fever, or typhoid, 169 
Enteritis, follicular, so-called, 180 
Ephemera, 89 

Epidemic of yellow fever at Lisbon, 251 
Epidemics of synocha, 86 
typhus, 167 
synocha, 86 
synochus, 86 
relapsing fever, 89 
sweating fever, 87 
typhoid, 223 
Eruption in typhoid, period of its oc- 
currence and character of, 172 
Eruptions on the skin in fever, 102 
erythematous patches, 106 
sudamina or miliary or sweat vesi- 
cles, 104 
maculae, 102 
petechias, 102 
vibices, 105 

purpura haemorrhagica, in spots, 
104 
in patches, 105 
rose-colored lenticular spots, 172 
freckles, lentigo, 106 
flea-bites, 106 
furunculi, or boils, 288 
Eruptions in typhus, 102 
Erysipelas in typhus, 154 
Erythema, nature and importance of, in 

typhus, 148 
Ether, nitric, sulphuric, or chloric, use 

of, in typhus, 165 
Evacuations, black or tarry, in typhoid, 

219 
Evacuations, characters of in typhoid, 

217 
Evaporating lotions to the head in ty- 
phus, 120 
Eustachian tube, thickening of mucous 

tissues of, in typhus, 154 
Euston, case of typhoid, 242 
Ewens, case of typhoid, 243 
Exudation, nature of, in inflammation, 

according to Virchow, 42 
Exudation, typhoid, into lung sub- 
stance, 185 
Eye, characters of, in typhus, 101 
ferrety, in typhus, 101 
expression and characters of, in sy- 
nocha, 74 

Face, characteristics of the face in sy- 
nocha, 100 ; in typhus, 100 
Facies typhosa, 170 

importance of for diagnosis, 210 



Faculties, mental state of, in yellow 

fever, 257 
Feces, involuntary discharge of, in ty- 
phus, 115 
Febricula, 89 

Febrifuge medicines in typhus, 161 
Febris bellica, 168 

miliaria, sweating fever, or " Eng- 
lish sickness," 87 

typhodes of old authors, 84 

assodes, lyngodes, phricodes, pitui- 
tosa, and lypinea of old authors, 
84 

hungarica, cholerica, mesenterica, 
febricula, biliosa, and lenta, 84 

nervosa, innarnmatoria, putrida, 84 

slow nervous fever of Huxham, 85 
Fever : — 

adynamic, 95 

asthenic, 95 

ataxic, 95 

Bulam, 53 

Crimean, 223 

endemic, 21, 52 

epidemic, 95 

enteric, 169 

eruptive, 48 

hemorrhagic, 272 

hectic, 47^ 

intermittent, 50 

jail, 95 

Irish, 95 

maculated, 95 

malignant, 95 

marsh, 47 

petechial, 95 

primary, 50 

putrid, 95 

pyogenic, 47 

Pythogenic, 169 

quartan, 51 

quotidian, 51 

remittent, 52 

secondary, 204 

sweating, 87 

tertian, 51 

typhus, 95 

typhoid, 169 

war plague, 251 

yellow, 248 

general prevalence and mortality 
from, 18 

in English armies, 18 

in French armies, 18 

mortality from, at Scutari, 18 

in Ireland, 19 

Bulam, 53 

and inflammation contrasted, 44, 45 

remittent, 248 

yellow, classification of, 248 ; gene- 
ral characters of, 248 ; various 
forms of, 250 



INDEX. 



355 



Fevers, classification of, 46 
Primary. 

Continued fevers : — 

synocha, or inflammatory fever, 
synoclius, or mixed or nervous 

fever, 
typhus or adynamic fever, spot- 
ted or Irish, fever, putrid fever, 
typhoid, or enteric fever. 
Intermittent fever, or ague : — 
quotidian, 
tertian, 
quartan. 
Remittent fever : — 

paludal fever, comprising marsh 
remittent, bilious remittent, 
and yellow fever. 
Irritative. 

gastric fever. 

gastro-intestinal remittent, 
hectic fever. 
Eruptive. 

variola, smallpox, 
rubeola, measles, 
scarlatina, scarlatina, 
miliaria, miliary or sweating fe- 
ver, 
general pathology of, 34 
summary of pathology of, 39 
shock, 40 
Flexure, sigmoid, of colon, dysenteric 

process in, 190 
Flint, case of typhoid, 237, 238 
Fomentations in typhoid tympanitis, 145 
Food and drink, nature and amount of, 
in synocha, 82; in typhus, 156; in 
typhoid, 214 
Food of man, probable influence of, in 
development of certain types of dis- 
ease, 87, 88 
Food and drink of patient in typhus, 156 
Foot, case of typhoid, 234, 235 
Fowelin and Volkmann, their experi- 
ments cited, 36 
Fracastor, of Verona, his account of epi- 
demic typhus in Italy cited, 95 
Friability of lung tissue in typhoid, 196 
Frolich and Lichtenfels, their experi- 
ments cited, 38 

Galen, his views on fever, 25, 30 
Gangrene of the lung in typhoid pneu- 
monia, 138. 
case of extensive, of pectoral mus- 
cle, 151 
of lungs in typhoid, 197 
of feet, toes, hands, &c, in typhus, 

101 
in typhus, 151 
Gargouillement in abscess of lung in 
typhus, 139 



Gastritis, danger of, from abuse of eme- 
tics in synocha, 76 
Gastric fever, 48 

so-called, 142 

phenomena, with anxiety and de- 
pression in yellow fever, 258 

symptoms in typhoid, 218 
Gierse, his researches cited, 30 
Gillings, case of typhoid, 246 
Glands, aggregate and solitary deposit 
in, in cholera typhoid, 206, 207 

intestinal typhoid lesions of, 180 

lenticular, of intestine, 175, 179 

follicular, of intestine, 175, 179 

palatal, 175 

buccal, 175 

oesophageal, 175 

gastric, 176, 178 

Brunner's, 176, 179 

Peyer's, 175, 176 

solitary, 175, 179 

agminated, 175, 179 

aggregated, 175, 179 

en grappe, 178 

of colon, 176 

of mesentery, 185 

parotid, 154 

mesenteric, rarely affected in ty- 
phus, 146 

mesenteric, typhoid lesions of, 185 

solitary and agminate, summary of 
various states of, in typhoid, 197 

of colon, state of, in typhoid, 176 
Gland swellings in various parts, in ty- 
phus, 152 
Gluge, Professor, on the state of the in- 
testinal glands in cholera, 206 
Grant, his works cited, 84 
Graves, Dr., of Dublin, his plan of treat- 
ing the delirium ferox of typhus 
by tartar emetic and opium, 122 

his remark that lie fed fevers, 156 
Gravity, specific, of lung consolidation 
in typhoid, 195, 196 

brain, 237 

heart, 235 

liver, 204, 317 

spleen, 203 

kidneys, 236 

intestines, 231 

aggregate glands, 200 

atrophied intestines, 240 

mesenteric glands, "2'VZ 
Gray, case of typhoid, 233 
Gregory, case of typhoid. 233 
Gurgling, with pain in ileo-ca?cal region, 

in typhoid, 171 
Gulf, Mexican, yellow fever in, 251 

Hair falling off after typhus, 167 
Hamilton, his method of treatment by 
purgatives, 77 



356 



INDEX. 



Hay fever, 89 

Head, shaving of the, in synocha, 74 

Head symptoms in synocha, 63, 64, 73, 

74, 75 
Healing process in typhoid nlcers, 192 
Heart, condition of, in typhoid, 197 

failure of circulation commencing 

at, 124 
modifications of sounds, and im- 
pulse of, in typhus, 124 
sledge-hammer pulsations of, 126 
diminution of impulse of, in ty- 
phus, 128 
faint sound of, in typhus, 128 
appearances found in post-mortem, 
fishy and semi-putrid state of, 
129 
rate and force of, in fever, 39 
violent thumping action of, in ty- 
phoid pneumonia, 140 
Heat, natural, or blood heat, 30 
fever heat, 29, 30 
in inflamed parts, 29 
seat of, increased, 31 
Hebetudo typhosa, 170 
Hectic fever, 48 
Helmholtz, researches on temperature 

cited, 32, 36 
Hemorrhage from bowels in typhus, an 
occasional, though not constant symp- 
tom, 146 

its probable connection with pur- 
pura haemorrhagica, 146 
intestinal, of only rare occurrence 

in typhus, 146 
from the intestines in typhoid, 219 
from nose, lips, eyes, ears, gums, 
tongue, lungs, stomach, intes- 
tines, vagina, &c, in yellow fe- 
ver, 253, 260 
in algid form of yellow fever, 253 
Hemorrhagic forms of yellow fever, 250 
Hepatization of lungs, red in typhoid, 

196 
Heslop and Lyons on cardiac murmur 

in relapsing fever, 91, 130 
Hewins, case of typhoid, 242, 243 
Hiccough, a bad sign, if persistent, 154 
Hippo, corruption of ipecacuanha, 76 
Hippocrates, 58 

fever described by, supposed by 

Bancroft to be yellow fever, 249 

Hoffmann's anodyne, use of. in synocha, 

79 
Hoffa and Ludwig, their experiments 

cited, 36 
Hydrargyrum cum creta, use of, in bron- 
chitis of typhus, 135 
Hypercatharsis, dangerous effects from, 
in typhus, 145 



Hypogastric region, necessity of careful 

exploration of, in typhus, 147 
Hysteria in females in yellow fever, 257 

Ice-cap, use of, in synocha, 75 

Iced drinks, 75 

Ileo-csecal region, pain and gurgling in, 

in typhoid, 171 
Ileum, glandular atrophy of, 202 

intestine engagement of, in typhoid. 
182 
Infarction, extreme, with typhoid de- 
posit of intestinal glands, 1S2 
Infiltration, purulent, in typhoid pneu- 
monia, 138 
stage of, in typhoid affections of 
intestinal glands 182 
Infiltration, typhoid, into intestinal 
glands, 180 
typhoid, into lung, 195 
Inflammation, its patholoey, contrasted 
with that of fever,"28, 39 
symptomatic quatrain of Celsus, 41 
temperature in, 42 
contrasted with fever, 43, 44, 45 
Insesta, necessity of regulating, in ty- 
phoid, 217 
Intermittent fevers, general characters 

of, 50, 51 
Intestines, profuse hemorrhage, in yel- 
low fever, 264 
secondary lesions of, in typhus, 142 
occasional and intercurrent, 142 
various forms of, 142 
anatomical states connected with 

143 
contrasted with lesions of typhoid. 
143 
Intestine, small, various states of, in 
cholera typhoid, 206 
large, various states of, in cholera 
typhoid, 207 
Intumescence follicular, cases of typhoid 

with, 227 
Inunction, mercurial, in typhus, 121 
Ipecacuanha as an emetic in synocha, 
78 
hibernice, "hippo," as an emetic, 
76 
Ireland, typhus epidemic in, 19 

periodic fever invasions in, 19, 21 
Irvine, case of, typhoid, 236 

James's powder, use of, in synocha, 79 
Jeaffrey, case of, typhoid, 247 
Jejunum, glandular atrophy of, 202 
Johnston, case of typhoid, 236, 237 
Jones, case of, typhoid, 227 
Juniper, use of, preparations of. in sup- 
pression of urine in typhus, 148 

Kausis, or febris ardens, 65 



INDEX. 



857 



Kidneys but rarely affected in typhus, 
146 
congestion of, in typhoid, 220 
in typhoid, 203 
rarely affected in synocha, 81 
typhoid lesion of, 185 

Labat, Pere, account of yellow fever, 251 
Laennec on the gluey or fishy state of 

the muscles in typhus, 129 
Langue perroquet, 108 
Leeches to the temples in typhus, 120 
in synocha, 73 
to the head in typhus, 120 
with poultices and fomentations to 
abdomen in typhoid, 216, 219 
Leister, case of, typhoid, 244 
Lenticular rose-colored spots of typhoid, 

172 
Lesions, secondary, of typhus feyer, 
general character of, 111 
secondary lesions of cerebral or- 
gans, 112 
circulating apparatus, 124 
lungs and pleura, 130 
intestines, 142 

solid viscera, including liver, 146 
spleen and kidneys, 146 
of cutaneous system, 148 
of the intestines in typhus, 142 
of typhoid, 192 

typhoid, of intestinal glands, 180 
Lice, development of, on person of ty- 
phus patient, 167 
Lichtenfels and Frolich, their experi- 
ments cited, 38 
Lieberkiihn, tubes or follicles of, 178, 

179 
Lindsay, case of, typhoid, 235, 236 
Liquor etheris oleosus, use of, in syno- 
cha, 79 
Lithates in excess in fever, 146 
Liver, in typhoid, 203 

in yellow fever, 317 
Lividity of face, with dyspnoea, in ca- 
pillary bronchitis of typhus, 133 
Lotions, cold, to the head, in synocha, 

74,75 
Lotions to the head, 74 
Louis, his researches referred to, 27 
his views as to the cerebral affec- 
tions in fever, 63 
observations on pathology of ty- 
phus, 116 
on the state of the heart in typhus, 

129 
on typhoid lesions of colon, 193 
Love, case of, typhoid, 232 
Ludwig and Hoffa, their experiments 

cited, 36 
Lung, infiltrations in typhoid, 195 

2 



Lungs hemorrhage from, in yellow fever, 
262 
sloughs of, in typhoid, 196 
collapse of, pulmonary tissue in 

typhoid, 196 
gangrene of, in typhoid, 197 
typhoid lesion of, 185 
nature of, 185 
Lyons and Heslop on cardiac murmur 

in relapsing fever, 91, 130 
Lyons, observations on pulse-rate and 

temperature, 38 
Lysis, or termination of fever, in syno- 
cha, 67 



Maculse, typhus, 102 
Madden, case of, typhoid, 231 
Mahogany tongue in typhus, 108 
Malaise, 54, 60 

Martin, Dr. J., on yellow fever, 292 
Massa typhosa, or typhoid matter, de- 
posit, softening, elimination, ul- 
cerative action, perforation, &c, 
consequent on, 180 
nature of, 129 
M'Bride, his account of typhus referred 

to, 168 
M'Gill, case of, typhoid, 229, 230 
Meat, solid, necessity for caution in use 

of, after typhus, 158 
Mercurialization in typhus rarely to be 

employed, 122 
Mercury and. chalk in bronchitis of 

typhus, 135 
Mesenteric glands, various conditions 
of, in typhus, 202 
rarely affected in typhus, 146 
typhoid lesions of, 185 
Metamorphosis increased in fever, 31, 
32,33 
increased, attended with elevation 
of temperature, 32, 33 
Meteorism, or gaseous distension of the 

abdomen, in typhus, 144 
Meteorology of Lisbon epidemics, 344 
Mexican Gulf, yellow fever in, 251 
Miliaria, or miliary fever, sweating fever 

or English sickness, 87 
Mindererus spirit, use of, in synocha, 70 
Moleschott, his views on the production 

of animal heat, 32 
Morphia, use and dangers of, in tvphus. 

119 
Morgagni, his views referred to, 26 
Mortality from typhus, 167 
Mortification of parts in typhus, 151 
Mouth, characters exhibited by, in ty- 
phus, 101 
Mucous membrane, atonic state of, with 
diarrhoea and tympanitis, in typhus, 
145 



358 



INDEX. 



Muriate of morphia, use and dangers I 

of, in typhus, 119 
Murmur, cardiac, in relapsing fever, 90 j 

in heart after fever, 90, 130 
Murray's fluid camphor, use of, in ty- 
phus, 159 
Muscular coat of intestines, partial de- 
struction of, in typhoid, 190 
Musk, use of, in typhus, 165 
Musk, use of, in controlling excitement, 

in typhus, 119 
Mustard, as an emetic in synocha, 76, 78 
emetic, in bronchial effusion of ty- 
phus, 136 



Napoleon's campaigns, typhus synco- 

palis during, 168 
Nerves, partial paralysis of certain 

nerves in typhus, 140 
Nervous system, part played by it in 
fever, 33, 34, 35, 36, 39 
moderator and regulator functions 

of, 39 
probable centre of regulating func- 
tion, 39 
vagi, 39 
sympathetic, 39 
medulla oblongata, 39 
Nicholas, case of, typhoid, 233 
Nitrate of potash, use of, in synocha, 79 
Nurse, important duties of, 75 

necessity and importance of a good, 

in synocha, 75 
in typhus, 55 

O'Connor, his account of typhus referred 

to, 168 
(Edema of mucous surface not found in 

choleraic typhoid, 208 
Opium and tartar-emetic in delirious 
form of typhus, 122 
may be used with good effect in 
typhus, under certain restric- 
tions, 119 
use of, in peritonitis, from perfora- 
tion, 219 
quantity of which may be required, 
219 
Osborne, case of, typhoid, 243, 244 

Pains in legs in yellow fever, 253 

Parotitis in typhus, 154 

Parchment-like degeneration of mucous 
membrane, 180 

Parrot's tongue, 108 

Patches of Peyer, extreme case of in- 
farction of, with typhoid deposit, 182 

Pediluvia in typhoid, 216 

Perforation of intestines in typhoid, 
212, 214 



Perforation of intestines in peritonitis, 

use of opium in, 218 
Periodics, use of, in typhus, 162 
Peritoneum, perforation of, 186 
Peritonitis from perforation in typhoid, 
186 
without actual perforation in ty- 
phoid, 212 
from perforation, use of opium in, 
218 
Perityphlitis in typhoid, 193 
Petechia? in typhus, 102 
Peyer, glands of, typhoid lesions in, 180 
Peyer's patches, deposit in, in choleraic 
typhoid, 206 
destruction of by sphacelus, in ty- 
phoid, 188, 190 
of, extreme case of infarction with 

typhoid deposit, 183 
period of maturation and decline of, 

177 
remarkable case of persistence of 
tumid state of, without ulcera- 
tion, 198 
state of, in typhoid, 198 
Phosphates in urine in late periods of 

bad typhus, 146 
Phrenitis, erroneous views as to, in fever, 

63 
Physic to be avoided in typhus, 160 
Physiognomy of typhus fever, 99 

peculiar, of algid form of yellow 
fever, 254 
Pike, case of, typhoid, 246 
Pleuritis in typhoid, 185, 190 
Pleuritis, secondary, more common in 
typhoid than in typhus fever, 141 
characters and treatment of, 141 
Pneumonia in typhus, 131 
characters of, 137 
often fatal, though engaging very 
limited portions of lung sub- 
stance, 138 
Polygala seneka as a stimulant expec- 
torant in typhoid bronchitis, 135 
Poppies, syrup of white, with tartar 

emetic, 123 
Poultices, value of, in abdominal lesions 

of typhoid, 216 
Prima? vise, first passages, the alimen- 
tary tract, 76 
Prior, case of, typhoid, 235 
Prostration, early and profound, in ty- 
phus, 99 
Pulmonary collapse in typhoid, 196 
Pulse and heart, want of uniformity in, 
form and volume of their contractions, 
124 
Pulse, characters of, in synocha, 65, 74 
in typhoid peritonitis, 213 
obliteration of, radial, in algid form 
of yellow fever, 252 



INDEX. 



359 



Pulse — Continued. 

rate of temperature, 38 ; frequency 
of pulse no measure of tempera- 
ture, 38 ; nor of completeness of 
circulation, 39 
total extinction of, in typhus, 126 
various characters and states of 

the, in typhus, 124 
with "kick" in it, 74 
Pulvis Jacobi veri as febrifuge in ty- 
phus, 161 
in synocha, 79, 80 
Punch, use of whiskey or brandy, in bad 

cases of typhus, 164 
Pupil, contraction of, in typhus, 121 

dilation of, in typhus, 121 
Pupils, dilatation of, with coma, in ty- 
phus, 115 
Purgatives, effect of, in rupturing con- 
servative adhesions, in cases of 
peritonitis from perforations, 214 
salutary uses of, in typhoid, 215 
use and abuse of, 76 
use and abuse of, in synocha, 76, 81 
Purpura hemorrhagica, 104 
in spots, 104 
in patches, 104 
Purpuric form of yellow fever, 250 

spots and patches in algid form of 
yellow fever, 252 
Pyretogen, fever-stuff of Eisenmann, 33 
Pyrexia, origin of term and pathological 

significance, 26 
Pythogenic, or enteric, or typhoid fever, 
169 

Quarantine, question of, in yellow fever, 

292 
Quinine as a general medicament in ty- 
phoid, 221 
sulphate of, in typhus, 162 

Rachialgia in yellow fever, 250 
Rain, fall at Lisbon, 346 
Rale, muco-crepitating, of bronchitis of 
typhus, 133 
sonorous and sibilant in do., 134 
Razor, danger of allowing patient in de- 
lirium ferox of typhus the use of cut- 
ting instruments, 120 
Reisseissen, bronchial muscles of, state 

of, in typhus, 133 
Relapsing fever, 89 

as an epidemic, 89 

not the famine fever, 89 

not a very fatal fever, 90 

symptoms of, 90 

durations and characters of first 

attack, 90 
of second attack, 91, 92 
as it occurred in the Crimea, 91 
treatment of, 93 



Relapse in synocha caused by excite- 
ment, 83 

Remission, period of, deception in ty- 
phoid, 174 

Remittent fever, 248 

fevers, general characters of, 52, 53 

Respiration, function of, in yellow fever, 
259 

Respiratory organs, secondary lesions of, 
in typhus, 130 

Reticulation of patches of Peyer, 187 

Revil, case of, typhoid, 244 

Rigors, 29 ; a peripheral phenomenon, 30 

Roger, his researches on temperature 
cited, 30 

Rogers, his account of typhus referred 
to, 168 

Rokitansky, his researches referred to, 27 
on typhoid lesions of intestinal 
glands, 180 

Rose-colored spots of typhoid, 172 

occasionally absent or invisible, 211 

Rules, practical, to determine if wine 
agrees with patients in typhus, 164 

Rutty, works of, referred to, 168 

Sago-grain condition of minute intes- 
tinal glands in cholera, 180 
state of intestinal glands in cholera, 
206, 209 
Saline aperients in synocha, 81 
Salines, use of, in synocha, 78 
Saragosa, typhus syncopalis, which pre- 
vailed during memorable siege of, 168 
Sargent, case of, typhoid, 236 
Schoenlein, his works referred to, 27 
Scrive, M., reports on diseases of French 

army, 22 
Secondary lesions of typhus, 111 
cerebral organs, 112 
circulating apparatus, 124 
lungs and pleurae, 130 
intestines, 142 

solid viscera, including liver, 146 
spleen and kidneys, 146 
cutaneous system, 148 
Seltzer water, use of, in synocha, 82 
Seneka polygala, use of, in typhoid 

bronchitis, 135 
Sex, influence of, in determining mor- 
tality in typhus, 168 
Shaving the head in synocha, 74 

in typhus, 118, 120 
Sighing, peculiar and fatal character of, 

in typhus, 153 
Sigmoid flexure of colon, dysenteric 

lesions in, 190 
Simple continued fevers. 54 
Sinapisms, use of, in typhoid, 216 
Signs, bad, in typhus, 152 
Sinking and failure of circulation not so 
general in typhoid as in typhus, 215 



360 



INDEX. 



Skin, appearance on, in typhus, 101 
Skin, characters presented by, in ty- 
phus, 173 
Skinner, case of, typhoid, 238 
Sleep, importance of, 70 

induced by stimulants in typhus, 

118 
in typhus, 109 
Sleeplessness, 74 

in typhus, 117 
Sloughs of cutaneous parts in typhus, 
148 
of pulmonary texture in typhoid, 
196 
Small intestines, state of, in cholera ty- 
phoid, 205 
Soda water, use of, in synocha, 82 
Solitary glands, deposit in, in cholera 

typhoid, 206 
Sordes, on the lips, gums, teeth, and 

tongue, in typhus, 101 
Sound, first, of heart diminished or lost 
in certain cases of typhus, 128 
prolongation of, after certain fevers, 
130 
Spasms, tonic and clonic, 115 
Specific gravity of brain, 237 
heart, 235 
lung, 235 
liver, 204, 317 
spleen, 203 
kidney, 236 
intestine, 231 
aggregate glands, 200 
atrophied intestines, 240 
mesenteric glands, 232 

Sphacelus of external parts in typhus, 
149 
of patches of Peyer in typhoid, 

188, 191 
of Peyer's patches, 180 

Sphincters of anus and urethra relaxed 
in typhus, 115 

Spirits of nitrous ether, use of, in sy- 
nocha, 79 

Spleen in typhoid, 203 

typhoid lesions of, 203 

Spots, purpuric, and patches in algid 
form of yellow fever, 253 

Squill, tincture of, in bronchitis of ty- 
phus, 135 

Stahl, doctrines of, 26 

Starvation in typhus, dangers of, 118 

Status gastricus saburralis, 72 

Stavis agria, use of, to destroy vermin 
in typhus, 167 

Stertorous breathing, with coma, in ty- 
phus, 115 

Stethoscope, use and necessity of, in 
typhus cases, 131, 134 

Sthenic form of yellow fever, 250 



Stimulants, period at which use of may 
be commenced in typhus, 163 
use of, in typhus, 110 
in typhoid, restricted use of, 220 
well borne in typhoid pneumonia. 

140 
their superior therapeutic effect in 
persons of naturally temperate 
habits, 141 
Stimulation as a means of controlling 

delirium in typhus, 118 
Stockton, case of, typhoid, 227 
Stokes, case related by, of patient in 
typhus eating beef and cabbage, 
157 
observations on pathology of ty- 
phus, 116 
Stomach, hemorrhages from, in yellow 
fever, 263 
overloaded state of, causing cere- 
bral excitement in typhus, 117 
state of, in cholera typhoid, 204 
symptoms referred to in typhoid, 
and treatment of, 204 
Strabismus in typhoid, 121 
Strait- waistcoat, rarely required in yel- 
low fever, 257 
use and abuse of, 75 
Stroke of the bar in yellow fever, 250 
Stupes, with turpentine, for tympanitis 

in typhus, 145 
Subsultus tendinum in typhus, 155 
Sudamina, or sweat vesicles, in typhus, 

104 
Sudorifics in synocha, use and abuse of, 

79 
Sulphate of magnesia in synocha, 81 
soda in synocha, 81 
of potash in synocha, 81 
of zinc as an emetic, 76 
of quinine as a general medicament 

in typhoid, 221 
of quinine in typhus, 162 
of zinc, as an emetic in synocha, 78 
Sulphates in urine, 81 
Suppression of urine, 80 
Sweat, profuse and persistent in typhus 

bronchitis, 133 
Sweating fever, or English sickness, re- 
ferred to, 71, 87 
not a salutary process when early 

or artificially induced, 71 
profuse, an unfavorable sign in ty- 
phoid pneumonia, 140 
salutary only when part of a gene- 
ral eliminative process, 72 
Sweats, 71 

Sweats favorable when the result of 
" coction," 71 
early or partial unfavorable, 71, 72 
continuous, a bad sign in typhus, 
152 



INDEX. 



361 



Sweat vesicles, or sudamina, in typhus, 

104 
Sydenham, 17 

prevalence of fever in his time, 18 
Symes, case of, typhoid, 230, 231 
Synocha and allied types of fever pro- 
bably less common now than former- 
ly, 86 
Synocha, 46 ; nature and predisposing 
causes of, 58, 59 ; general symp- 
toms of, 60 
complications in, 72 
inflammations of brain rare in, 72 
foul tongue in, 72 
treatment of, 73 
general management of, 82 
practical rules in, 78 
Synochus, 46, 88 

simplex, of old authors, 84 

Taches roses lenticulaires of typhoid, 

172 
Tannahill, case of, typhoid, 239, 240 
Tartar emetic, its therapeutic uses in 

synocha, 78 
Tartar emetic and opium in delirium 
ferox of typhus, 122 
and musk, 123 
emetic, danger of its use in catarrh 

of typhus, 135 
employment of, 76 
with opium, 122 
with musk, 123 

emetic ointment, use of to the head 
in typhus, 118 
Temperature in fever, 26 ; degrees of 
elevation of, 30 ; in inflammation, 
42 
seat of increased, 31 
origin of increased, 31 
and pulse rate, 38 
in typhoid, 173 
marked elevation in abdomen in 

typhoid, 173 
in yellow fever, 249 
Temples, throbbing of, in synocha, 78 
Thermometer, observations of De Haen, 

Traube, &c, on, 30, 34 
Thirst often a troublesome symptom in 

typhus, 158 
Thompson, observations on temperature 

in cold stage of fever, 55 
Thorax, typhoid lesions in, 194 
Tongue, state of, in typhus, 107 
Tonics, use of, with chalybeates in the 

sequelae of relapsing fever, 94 
Toogood, case of, typhoid, 241, 242 
Towel, use of the Turkish, in typhus, 

159 
Trachea, condition of, in typhus, 132 
Traube, his researches cited, 30, 36, 37 



Treatment of typhus, 155 
of typhoid fever, 210 
Tremor of tongue and. of body generally 

in typhus, 114 
Tubuli uriniferi, state of, in typhoid, 203 
Turpentine as a stimulant expectorant 
in typhus, 136 
stupes in typhoid tympanitis, 145 
use of, as a stimulant expectorant 
in typhoid pneumonia, 140 
Tympanitis, with an atonic state of in- 
testines and diarrhoea in typhus, 144 
Typhoid fever as it occurred during 
Crimean campaign, 223 
with interval of partial convales- 
cence, 221 
treatment of, 210 

practical distinction of two forms 
of, in reference to treatment, 211 
latency of symptoms of, 173 
practical division of cases of, 174 
or enteric fever, 169 
lesions of intestinal glands, 180 
Typhosis, various forms of disease in- 
cluded under head of, 96 
Typhous fevers, general account of, 95, 
96 
comprises putrid and malignant 
fevers, jail and hospital fevers, 
camp fever, febris bellica, spotted 
maculated or petechial fever, and 
typhoid, enteric, or pythogenic 
fever, 95 
geographical limits of typhus, 95 
form of yellow fever, 250 
Typhus does not impair constitution, 
166 
confers a certain amount of immu- 
nity against a recurrence of same 
disease, 166 
constitution often appears reno- 
vated after, 166 
tendency to obesity after, 167 
patient's life ought to be insurable 

after, 167 
and typhoid fevers, identity or non- 
identity of, considered, 97 
gravior, 151 

icterodes,a form of yellow fever, 251 
Typhus or spotted fever, clinical cha- 
racters of, 97 
pure uncomplicated, 110 
syncopalis at siege of Saragossa, 16S 

Ulceration, typhoid, in intestinal glands, 

180 
Ulcerations of the intestines compara- 
tively rare in typhus, 144 
few, small, and irregular in typhus. 

144 
numerous, regular, and progressive 
in typhoid, 144 



362 



INDEX, 



Ulcers, enteric, in typhoid, 189, 191, 192 
Urine, ammoniacal, in late periods of 
typhus, 146 
characters of, in synocha, 81 
dribbling of, with retention, 147 
involuntary discharge of, in ty- 
phus, 115 
suppression of, in typhus, 147 

Vagi nerves, irritation conveyed through 
from mucous surface to brain, 
117 
part played by them in fever, 36, 37 
revulsive action, induced through 
their gastric filaments, by eme- 
tics, 76 
Vagina, hemorrhage from, in yellow 

fever, 265 
Vahez, case of, typhoid, 230 
Valsalva, his views referred to, 26 
Valve, ileo-colic, gland of Peyer upon, 

176 
Vascularity, intense, of intestines, me- 
senteric glands, &c. in typhoid, 181 
Venesection in synocha, 65, 66, 67, 73 
proper therapeutic use of in syno- 
cha, 77 
Ventilation and cleanliness, value of, in 
treatment of typhoid, 167 
importance of in typhus, 167 
Vera Cruz, yellow fever epidemics in, 

251 
Vesication, by blisters to the head, in 

synocha, 75 
Vibices, 105 
Vinegar, external application of, with 

sponge, in typhus, 159 
Virchow, on oedema of mucous surface, 
in choleraic typhoid, 208 
his views and researches referred 
to, 28, 39, 41 
Volkmann and Fowelin, their observa- 
tions cited, 36 
Vomiting, bilious, in relapsing fever, 93 

" Walking cases" of yellow fever, 250 



Wakefulness a bad sign in typhus, 152 
Walton, case of, typhoid, 245, 246 
Warm drinks, use of, in synocha, 79 
Warren, case of, typhoid, 238, 239 
Water, affusion with cold, in synocha, 
74 
cold, may be used in moderation in 
fever, 82 
Weber, his observations cited, 36, 41 
West Indies, yellow fever in, 251 
Whiskey, use of, in form of punch in 
typhus, 164 
use of, in controlling delirious ex- 
citement in typhus, 118 
Wilton, case of, typhoid, 229 
Wine and other stimulants in typhoid, 
220 
port, sherry, Madeira, when prefer- 
able to clarets, 220 
in typhus, 159 
danger of its use in typhus, if it 

excites heart, 163 
Lafitte, Chateau Margaux, Volnay, 
Chambertin,sherry,Madeira,port, 
effervescent French, or Rhenish, 
various uses of, in typhus, 164 
period at which use of, may be 

commenced in typhus, 163 
practical rules to determine if it 
agrees with patient in typhus, 165 
use of, in controlling delirious ex- 
citement in typhus, 118 

Yellow fever, classification of, 248 
general character of, 255 
various forms of, 250 
pathology of, 293 
treatment of, 289 
Yellow fever often a misnomer as to 

yellowness of skin, 255 
Yellowness of skin occasionally absent 
in yellow fever, 255, 259 

Zimmerman, his researches cited, 30 
Zinc, sulphate of, as emetic, 76 
as an emetic in synocha, 78 



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work within a reasonable compass, these additions have resulted in a considerable enlargement. 
It is, therefore, hoped that it will be found fully up to the present condition o( the subject, and that 
the reputation of the volume as a clear, complete, and compendious manual, will be fully maintained. 



BLANCHARD & LEA'S MEDICAL 



BUDD (GEORGE), M. D., F. Ft. S., 

Professor of Medicine in King's College, London. 

ON DISEASES OE THE LIVER. Third American, from the third and 

enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- 
fully colored plates, and numerous wood-cuts. pp. 500. $3 00. 

Has fairly established for itself a place among the is not perceptibly changed, the history of liver dis- 

classical medical literature of England. — British eases is made more complete, and is kept upon a level 

and Foreign Medico-Chir. Review, July, 1857. i with the progress of modern science. It is the best 

Dr. Budd's Treatise on Diseases of the Liver is \ work on Diseases of the^Liver in any language.— 

now a standard work in Medical literature, and dur- 



London Med. Times and Gazette, June 27, 1857. 



ing the intervals which have elapsed between the This work, now the standard book of reference on 
successive editions, the author has incorporated into j the diseases of which it treats, has been carefully 
the text the most striking novelties which have cha- ; revised, and many new illustrations of the views of 
racterized the recent progress of hepatic physiolog5^ \ the learned author added in the present edition. — 
and pathology; so that although the size of the book i Dublin Quarterly Journal, Aug. 1857. 

BY THE SAME AUTHOR. 

ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF 

THE STOMACH. In one neat octavo volume, extra cloth. $1 50. 



BUCKNILL (J. C.) } M. P., 

Medical Superintendent of the Devon County Lunatic Asylum; and 
DANIEL H. TUKE, M. D., 

Visiting Medical Officer to the York Retreat. 

A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, 

Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With 

a Plate. " In ore handsome octavo volume, of 536 pages. S3 00. 

The increase of mental disease in its various forms, and the difficult questions to which it is 
constantly giving rise, reader the subject one of daily enhanced interest, requiring on the part of 
the physician a constantly greater familiarity with this, the most perplexing branch of his profes- 
sion. At the same time there has been for some years no work accessible in this country, present- 
ing the results of recent investigations in the Diagnosis and Prognosis of Insanity, and the greatly 
improved methods of treatment which have done so much in alleviating the condition or restoring 
the health of the insane. To fill this vacancy the publishers present this volume, assured that 
the distinguished reputation and experience of the authors will entitle it at once to the confidence 
of both student and practitioner. Its scope may be gathered from the declaration of the authors 
that "their aim has been to supply a text- book which may serve as a guide in the acquisition oi 
such knowledge, sufficiently elementary to be adapted to the wants of the student, and sufficiently 
modern in its views and explicit in its teachiug to suffice for the demands of the practitioner." 



BENNETT (J. HUGHES), M. D., F. R. S. E., 

Professor of Clinical Medicine in the University of Edinburgh, &c. 

THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- 

LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken 
for or associated with, Phthisis. One vol. 8vo.,extra cloth, with wood-cuts. pp. 130. §1 25. 



BENNETT (HENRY), M . D. 
A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, 

ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. To which 
is added, a Review of the present state of Uterine Pathology. Fifth American, from the third 
English edition. In one octavo volume, of about 500 pages, extra cloth. $2 00. (Now Ready.) 
The ill health of the author having prevented the promised revision of this work, the present 

edition is a reprint of the last, without alteration. As the volume has been for some time out of 

print, gentlemen desiring copies can now procure them. 



BOWMAN (JOHN E.), M.D. 
PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- 
rican, from the third and revised English Edition. In one neat volume, royal 12mo., extra cloth, 
with numerous illustrations, pp. 2S8. $1 25. 

BY THE SAME AUTHOR. 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- 
LYSIS. Second American, from the second and revised London edition. With numerous illus- 
trations. In one neat vol., royal 12mo., extra cloth, pp. 350. SI 25. 



BSALE ON THE LAWS OF HEALTH IN RE- I BUCKLER ON THE ETIOLOGY, PATHOLOGY, 



iATION TO MIND AND BODY. A Series of 
Letters from an old Practitioner to a Patient. In 
one volume, royal 12mo., extra cloth, pp. 296. 
80 cents. 

BUSHNAN'S PHYSIOLOGY OF ANIMAL AND 
VEGETABLE LIFE; a Popular Treatise on the 
Functions and Phenomena of Organic Life. In 
one handsome royal 12mo. volume, extra cloth 



AND TREATMENT OF FIBRO-BRONCHI- 
TIS AND RHEUMATIC PNEUMONIA. In 
one 8vo. volume, extra cloth, pp. 150. SI 25. 
BLOOD AND URINE (MANUALS ON). BY 
JOHN WILLIAM GRIFFITH, G. OWEN 
REESE, AND ALFRED MARKWICK. One 
thick volume, roval 12mo., extra cloth, with 
plates, pp. 460. $1 25. 
with over 100 illustrations, pp.234'. 80 cents. ! BRODIE'S CLINICAL LECTURES ON SUR- 
GERY. 1 vol. 8vo. cloth. 350 pp. SI 25. 



AND SCIENTIFIC PUBLICATIONS 



BARCLAY (A. W.), M. D., 

Assistant Physician to St. George's Hospital, &c. 

A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs 
StelT * ° SeaSe * Inoneneat °ctavo volume, extra cloth, of 424 pages. $2 00. {Lately 



Of works exclusively devoted to this important 
branch, our profession has at command, compara- 
tively, but few, and, therefore, in the publication of 
the present work, Messrs. Blanchard & Lea have 
conferred a great favor upon us. Dr. Barclay, from 
having occupied, for a long period, the position of 
Medical Registrar at St. George's Hospital, pos- 
sessed advantages for correct observation and reli- 
able conclusions, as to the significance of symptoms 
which have fallen to the lot of but few, either in 
his own or any other country. He has carefully 
systematized the results of his observation of over 
twelve thousand patients, and by his diligence and 
judicious classification, the profession has been 
presented with the most convenient and reliable 
work on the subject of Diagnosis that it has been 
our good fortune ever to examine; we can, there- 
fore, say of Dr. Barclay's work, that, from his sys- 
tematic manner of arrangement, his work is one of 
the best works " for reference" in the daily emer- 
gencies of the practitioner, with which we are ac- 
quainted ; but, at the same time, we would recom- 
mend our readers, especially the younger ones, to 
read thoroughly and study diligently the whole, work, 
and the "emergencies" will not occur so often.— 
Southern Med. and Surg. Journ., March, 1858. 

To give this information, to supply this admitted 
deficiency, is the object of Dr. Barclay's Manual. 



The task of composing such a work is neither an 
easy nor a light one ; but Dr. Barclay has performed 
it in a manner which meets our most unqualified 
approbation. He is no mere theorist; he knows his 
work thoroughly, and in attempting to perform it, 
has not exceeded his powers.— British Med. Journal, 
Dec. 5, 1857. ' 

We venture to predict that the work will be de- 
servedly popular, and soon become, like Watson's 
1 ractice, an indispensable necessity to the practi- 
tioner.— N. A. Med. Journal, April, 1858. 

An inestimable work of reference for the young 
practitioner and student— Nashville Med. Journal, 
May, 1858. 

We hope the volume will have an extensive cir- 
culation, not among students of medicine only, but 
practitioners also. They will never regret a faith- 
ful study of its pages.— Cincinnati Lancet, Mar. '58. 

An important acquisition to medical liter iture. 
It is a work of high merit, both from the vast im- 
portance of the subject upon which it treats, and 
also from the real ability displayed in its elabora- 
tion. In conclusion, let us bespeak for this volume 
that attention of every student of our art which it 
so richly deserves - that place in every medical 
library which it can so well adorn.— Peninsular 
Medical Journal, Sept. 1858. 



BARLOW (GEORGE H.), M. D. 

Physician to Guy's Hospital, London, See. 

A F M c™ A M L n ° P I HB f „ P A ACTI ?5 0P MEDICINE. With Additions bv D. 

WerecommendDr.Barlow'sManualinthewarm 
est manner as a most valuable vade-mecum. We 
have had frequent occasion to consult it, and have 
found it clear, concise, practical, and sound. It is 



eminently a practical work, containing all that is 
essential, and avoiding useless theoretical discus- 
sion. The work supplies what has been for some 
time wanting, a manual of practice based upon mo- 
dern discoveries in pathology and rational views of 
treatment of disease. It is especially intended for 
the use of students and junior practitioners, but it 



will be found hardly less useful to the experienced 
physician. The American editor has added to the 
work three chapters— on Cholera Infantum, Yellow 
Fever, and Cerebro-spinal Meningitis. These addi- 
tions, the two first of which are indispensable to a 
work on practice destined for the profession in this 
country, are executed with great judgment and fi- 
delity, by Dr. Condie, who has also succeeded hap- 
pily in imitating the conciseness and clearness of 
style which are such agreeable characteristics of 
the original book.— Boston Med. and Surg. Journal 



BARTLETT (EUSHA). M. D. 

THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS 

?f F -p T ^ UNIT ED STATES A new and revised edition. By Alonzo Clark, M. D., Prof. 

of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, & c . In 

one octavo volume, of six hundred pages, extra cloth. Price $3 00. 

It is the best work on fevers which has emanated 
from the American press ; and the present editor has 
carefully availed himself of all information exist- 
ing upon the subject in the Old and New World, so 
that the doctrines advanced are brought down to the 
latest date in the progress of this department of 
Medical Science.— London Med. Times and Gazette, 
May 2, 1857. ' 

This excellent monograph on febrile disease, has 
stood deservedly high since its first publication. It 
will be seen that it has now reached its fourth edi- 
tion under the supervision of Prof. A. Clark, a gen- 
tleman who, from the nature of his studies and pur- 
suits, is well calculated to appreciate and discuss 
the many intricate and difficult questions in patho- 



logy. His annotations add much to the interest ot 
the work, and have brought it well up to the condi- 
tion of the science as it exists at the present day 
in regard to this class of diseases.— Southern Med 
and Surg. Journal, Mar. 1857. 

It is a work of great practical value and interest 
containing much that is new relative to the several 
diseases of which it treats, and, with the add it ions 
of the editor, is fully up to the times. The distinct- 
ive features of the different forms of fever are plainly 
and forcibly portrayed, and the lines of demarcation 
carefully and accurately drawn, and to the Ameri- 
can practitioner is a more valuable and safe ruide 

than any work on fever extant Ohio Med. and 

Surg. Journal, May, 1^57. 



BROWN (ISAAC BAKER), 

Surgeon- Accoucheur to St. Mary's Hospital, Sec. 

DN SOME DISEASES OF WOMEN ADMITTING OF SURGIC \L TRE VT- 

MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp. 276. $l 60 

io^Vn B ^ W n n „i iaS , ea T df i ,rhi V nSe J f a h i8* reputa- [ and merit the careful attention of every nmon. 

ion m the operative treatment of sundry diseases accoucheur.-^Moewtfon Journal «■««*■ 

■nd injuries to which females are peculiarly subject. wwnm jounua. 

Ve can truly say of his work that it is an important ^Y e have no hesitation in recommending this book 

■ddition to obstetrical literature. The operative t<> t«ic careful attention ot all Burgeons who mak* 

uggestions and contrivances which Mr. Brown do- female complaints a part ot their study and pr«oti"-s. 

cribes, exhibit much practical sagacity and skill, — Dublin (quarterly Journal. 



6 



BLANCHARD & LEA'S MEDICAL 



CARPENTER (WILLIAM B.), M. D., F. R. S., &c, 

Examiner in Physiology and Comparative Anatomy in the University of London. 

PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to 

Wcholo-y, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from 
thVfa* and revised London edition. With nearly three hundred illustrations. Edited with add - 

£ by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in 
vani 



^TaMeJicaS 



Xrge pages, handsomely printed and strongly bound in leather, with raised bands. $4 25. 

In the preparation of this new edition, the author has spared no labor to render it, as heretofore, 
a complete and lucid exposition of the most advanced condition of its important subject. The 
amoTnto the "additions required to effect this object thoroughly, joined to the former large size o 
S volume presenting objections arising from the unwieldy bulk of the work, he has omitted all 
hoi do Sions not bearing directly upon Human Physiology, designing to incorporate them in 
hi fonhcomm^ Treatise on General Physiology. As a full and accurate text-book on the Phy- 
sfolosv o ? Man, the work in its present condition therefore presents even greater claims upon 
indent and physician than those which have heretofore won for it the very wide and distin- 
^ied favo? which it has so long enjoyed. The additions of Prof. Smith will be found to supply 
S ^!ver^ Y h^ebeenw^tmgloi^ American student, while the introduction of many new 
mustTa^ionTandthe most careful mechanical execution, render the volume one of the most at- 
tractive as yet issued. 

Pnr nnwards of thirteen years Dr. Carpenter's I To eulogize this great work would be superfluous. 

. F _?5^?^ r i S IS™^ the profession eene- I We should observe, however that in this edition 

the author has remodelled a large portion of the 



work has been considered by the profession gene 



rallv both in This rcountry and England, as the most , the author has remodelled a large portion ot ne 
valuable compendium on^he subject of physiology , former, and the editor .has added ™^J patter of m- 
in mVr lan<*ua<?e This distinction it owes to the high j terest, especially in the form ot illustrations, we 
attainnStra^d unwearied industry of its accaL may ^confidently ^om^^^emo^^U^ 



plished author. The present edition (which, like the 
last American one, was prepared by the author him- 
self) is the result of such extensive revision, that it 
may 'almost be considered a new work. We need 
hardly say, in concluding this brief notice, that while 
the work is indispensable to every student of medi- 
cine in this country, it will amply repay the practi- 
tioner for its perusal by the interest and value of its 
contents.— B oston Med. and Surg. Journal. 

This is a standard work— the text-book used by all 
medical students who read the English language. 
It has passed through several editions in order to 
keep pace with the rapidly growing science of Phy- 
siology. Nothing need be said in its praise, for its 
merits are universally known ; we have nothing to 
say of its defects, for they only appear where the 
science of which it treats is incomplete.— Western 
Lancet. 

The most complete exposition of physiology which 
any language can at present give.— Brit, and For. 
Med.-Chirurg. Review. 

The greatest, the most reliable, and the best book 
on the subject which we know of in the English 
language. — Stethoscope. 



work on Human Physiology in our language.— 
Southern Med. and Surg. Journal. 

The most complete work on the science in our 
language. — Am. Med. Journal. 

The most complete work now extant in our lan- 
guage.— N. O. Med. Register. 

The best text-book in the language on this ex- 
tensive subject. — London Med. Times. 

A complete cyclopaedia of this branch of science. 
— N. Y. Med. Times. 

The profession of this country, and perhaps also 
of Europe, have anxiously and for some time awaited 
the announcement of this new edition of Carpenter's 
Human Physiology. His former editions have for 
many years been almost the only text-book on Phy- 
siology in all our medical schools, and its circula- 
tion among the profession has been unsurpassed by 
any work in any department of medical science. 

It is quite unnecessary for us to speak of this 
work as its merits would justify. The mere an- 
nouncement of its appearance will afford the highest 
pleasure to every student of Physiology, while its 
perusal will be of infinite service in advancing 
physiological science.— Ohio Med. and Surg. Journ. 



BY THE SAME AUTHOR. 

PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from 

the Fourth and Revised London edition. In one large and handsome octavo volume, ™th over 
three hundred beautiful illustrations, pp. 752. Extra cloth, $4 80 ; leather, raised bands, $5 25. 
The delay which has existed in the appearance of this work has been caused by the very thorough 
revision and remodelling which it has undergone at the hands of the author and the large number 
of new illustrations which have been prepared for it It will, therefore, be found almost a new 
work, and fully up to the day in every department of the subject, rendering it a reliable text-book 
for al Sudents engaged in this branch of science. Every effort has been made to render its typo- 
graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the 
mechanical arts of this country. 



This book should not only be read but thoroughly 
studied by every member of the profession. None 
are too wise or old, to be benefited thereby. But 
especially to the younger class would we cordially 
commend it as best fitted of any work in the English 
language to qualify them for the reception and com- 
prehension of those truths which are daily being de- 
veloped in physiology .—Medical Counsellor. 

Without pretending to it, it is an encyclopedia of 
the subject, accurate and complete in all respects— 
a truthful reflection of the advanced state at which 
the science has now arrived.— Dublin Quarterly 
Journal of Medical Science. 

A truly magnificent work— in itself a perfect phy- 
siological study.— Banking's Abstract. 

This work stands without its fellow. It is one 
few men in Europe could have undertaken ; it is one 



no man, we believe, could have brought to so suc- 
cessful an issue as Dr. Carpenter. It required for 
its production a physiologist at once deeply read in 
the labors of others, capable of taking a general, 
critical, and unprejudiced view of those labors, and 
of combining the varied, heterogeneous materials at 
his disposal, so as to form an harmonious whole. 
We feel that this abstract can give the reader a very 
imperfect idea of the fulness of this work, and no 
idea of its unity, of the admirable manner in which 
material has been brought, from the most various 
sources, to conduce to its completeness, of the lucid- 
ity of the reasoning it contains, or of the clearness 
of language in which the whole is clothed. JNotthe 
profession onlv, but the scientific world at large, 
must feel deeply indebted to Dr. Carpenter for this 
great work. It must, indeed, add largely even to 
his high reputation.— Medical Times. 



AND SCIENTIFIC PUBLICATIONS 



CARPENTER (WILLIAM B.), M. D., F. R. S., 

Examiner in Physiology and Comparative Anatomy in the University of London. 

THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- 

taming the Applications of the Microscope to Clinical Medicine, &c. By F. G. Smith, M. D. 
Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and verv 
handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50. 

Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher, 
eminently qualify him to produce what has long been wanted — a good text-book on the practical 
use of the microscope. In the present volume his object has been, as stated in his Preface, " to 
combine, within a moderate compass, that information with regard to the use of his ' tools,' which 
is most essential to the working microscopist, with such an account of the objects best fitted for 
his study, as might qualify him to comprehend what he observes, and might thus prepare him to 
benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- 
plishing this, no one acquainted with his previous labors can doubt. 

The great importance of the microscope as a means of diagnosis, and the number of microsco- 
pists who are also physicians, have induced the American publishers, with the author's approval, to 
add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to 
clinical medicine, together with an account of American Microscopes, their modifications and 
accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is 
hoped, will adapt the volume more particularly to the use of the American student. 

Every care has been taken in the mechanical execution of the work, which is confidently pre- 
sented as in no respect inferior to the choicest productions of the London press. 

The mode in which the author has executed his intentions may be gathered from the following 
condensed synopsis of the 

CONTENTS. 

Introduction — History of the Microscope. Chap. I. Optical Principles of the Microscope. 
Chap. II. Construction of the Microscope. Chap. III. Accessory Apparatus. Chap. IV. 
Management of the Microscope Chap. V. Preparation, Mounting, and Collection of Objects. 
Chap. VI. Microscopic Forms of Vegetable Life — Protophytes. Chap. VII. Higher Cryptoga- 
mia. Chap. VIII. Phanerogamic Plants. Chap. IX. Microscopic Forms of Animal Life — Pro- 
tozoa — Animalcules. Chap. X. Foraminifera, Polycystina, and Sponges. Chap. XI. Zoophytes. 
Chap. XII. Echinodermata. Chap. XIII. Polyzoa and Compound Tunicata. Chap. XIV. 
Molluscous Animals Generally. Chap. XV. Annulosa. Chap. XVI. Crustacea. Chap. XVII. 
Insects and Arachnida. Chap. XVIII. Vertebrated Animals. Chap. XIX. Applications of the 
Microscope to Geology. Chap. XX. Inorganic or Mineral Kingdom — Polarization. Appendix. 
Microscope as a means of Diagnosis — Injections — Microscopes of American Manufacture. 



Those who are acquainted with Dr. Carpenter's 
previous writings on Animal and Vegetable Physio- 
logy, will fully understand how vast a store of know- 
ledge he is able to bring to bear upon so comprehen- 
sive a subject as the revelations of the microscope ; 
and even those who have no previous acquaintance 
with the construction or uses of this instrument, 
will find abundance of information conveyed in clear 
and simple language. — Med. Times and Gazette. 

Although originally not intended as a strictly 



medical work, the additions by Prof. Smith give it 
a positive claim upon the profession, for which we 
doubt not he will receive their sincere thanks. In- 
deed, we know not where the student of medicine 
will find such a complete and satisfactory collection 
of microscopic facts bearing upon physiology and 
practical medicine as is contained in Prof. Smith's 
appendix; and this of itself, it seems to us, is fully 
worth the cost of the volume. — Louisville Medical 
Review. Nov. 1856. 



BY THE SAME AUTHOR. 

ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- 

LOGICAL ANATOMY. Second American, from a new and revised London edition. With 

one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. 

$3 00. 

In publishing the first edition of this work, its title was altered from that of the London volume, 
by the substitution of the word " Elements" for that of " Manual," and with the author's sanction 
the title of "Elements" is still retained as being more expressive of the scope of the treatise. 



To say that it is the best manual of Physiology 
now before the public, would not do sufficient justice 
to the author. — Buffalo Medical Journal. 

In his former works it would seem that he had 
exhausted the subjectof Physiology. In the present, 
hegivestheessence,asitwere, of the whole. — N. Y. 
Journal of Medicine. 



Those who have occasion for an elementary trea- 
tise on Physiology, cannot do better than to possess 
themselves of the manual of Dr. Carpenter. — Medical 
Examiner. 

The best and most complete expose" of modern 
Physiology, in one volume, extant in the English 
language. — St. Louis Medical Journal. 



BY the same author. (Preparing.) 

PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC 

CHEMISTRY AND HISTOLOGY". With a General Sketch of the Vegetable and Animal 
Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. 
The subject of general physiology having been omitted in the last editions of the author's « Com- 
parative Physiology" and "Human Physiology," he has undertaken to prepare a volume which 
?hall present it more thoroughly and fully than has yet been attempted, and which may be regarded 
as an introduction to his other works. 

BY THE SAME AUTHOR. 

A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH 

AND DISEASE. New edition, with a Preface by D. F. Condte, M. D., and explanations of 
scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. 



BLANCHARD & LEA'S MEDICAL 



COND1E (D. F.), M. D., &c. 
A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth 

edition, revised and augmented. In one large volume, 8vo., leather, of over 750 pages. $3 25. 

{Just Issued, 1859.) 

In presenting a new and revised edition of this favorite work, the publishers have only to state 
that the author has endeavored to render it in every respect "a complete and faithful exposition of 
the pathology and therapeutics of the maladies incident to the earlier stages of existence — a full 
and exact account of the diseases of infancy and childhood." To accomplish this he has subjected 
the whole work to a careful and thorough revision, rewriting a considerable portion, and adding 
several new chapters. In this manner it is hoped that any deficiencies which may have previously 
existed have been supplied, that the recent labors of practitioners and observers have been tho- 
roughly incorporated, and that in every point the work will be found to maintain the high reputation 
it has enjoyed as a complete and thoroughly practical book of reference in infantile affections. 

A few notices of previous editions are subjoined. 



Dr. Condie's scholarship, acumen, industry, and 
practical sense are manifested in this, as in all his 
numerous contributions to science. — Br. Holmes'' s 
Report to the American Medical Association. 

Taken as a whole, in our judgment, Dr. Condie's 
Treatise is the one from the perusal of which the 
practitioner in this country will rise with the great- 
est satisfaction.— Western Journal of Medicine and 
Surgery. 

One of the best works upon the Diseases of Chil- 
dren in the English language. — Western Lancet. 

We feel assured from actual experience that no 
physician's library can be complete without a copy 
of this work. — N. Y. Journal of Medicine. 

A veritable paediatric encyclopaedia, and an honor 
to American medical literature. — Ohio Medical and 
Surgical Jo7irnal. 

We feel persuaded that the American medical pro- 
fession will soon regard it not only as a very good, 
but as the very best "Practical Treatise on the 
Diseases of Children." — American Medical Journal. 

In the department of infantile therapeutics, the 
work of Dr. Condie is considered one of the best 
which has been published in the English language. 
— The Stethoscope. 



We pronounced the first edition to be the best 
work on the diseases of children in the English 
language, and, notwithstanding all that has been 
published, we still regard it in that light. — Medical 
Examiner. 

The value of works by native authors on the dis- 
eases which the physician is called upon to combat, 
will be appreciated by all; and the work of Dr. Con- 
die has gained for itself the character of a safe guide 
for students, and a useful work for consultation by 
those engaged in practice. — N. Y. Med. Times. 

This is the fourth edition of this deservedly popu- 
lar treatise. During the interval since the last edi- 
tion, it has been subjected to a thorough revision 
by the author; and all new observations in the 
pathology and therapeutics of children have been 
included in the present volume. As we said before, 
we do not know of a better book on diseases of chil- 
dren, and to a large part of its recommendations we 
yield an unhesitating concurrence. — Buffalo Med. 
Journal. 

Perhaps the most full and complete work now be- 
fore the profession of the United States; indeed, we 
may say in the English language. It is vastly supe- 
rior to most of its predecessors. — Transylvania Med. 
Journal. 



CHFUST5SON (ROBERT), M. D., V. P. R. S. E., &e. 
A DISPENSATORY; or. Commentary on the Pharmacopoeias of Great Britain 
and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- 
tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- 
proved, with a Supplement containing the most important New Remedies. With copious Addi- 
tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. 
In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 59. 



COOPER (BRANSBY B.), F. R. S. 
LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY- 

In one very large octavo volume, extra cloth, of 750 pages. $3 00. 



COOPER ON DISLOCATIONS AND FRAC- 
TURES OF THE JOINTS.— Edited by Bransby 
B. Cooper, F.R.S., &c. With additional Ob- 
servations by Prof. J. C. Warren. A new Ame- 
rican edition. In one handsome octavo volume, 
extra cloth, of about 500 pages, with numerous 
illustrations on wood. S3 25. 

COOPER ON THE ANATOMY AND DISEASES 
OF THE BREAST, with twenty-five Miscellane- 
ous and Surgical Papers. One large volume, im- 
perial 8vo., extra cloth, with 252 figures, on 36 
plates. $2 50. 

COOPER ON THE STRUCTURE AND DIS- 
EASES OF THE TESTIS, AND ON THE 
THYMUS GLAND. One vol. imperial 8vo., ex- 
tra cloth, with 177 figures on 29 plates. $2 00. 



COPLAND ON THE CAUSES, NATURE, AND 
TREATMENT OF PALSY AND APOPLEXY. 

In one volume, royal 12mo., extra cloth, pp. 326. 
80 cents. 

CLYMER ON FEVERS; THEIR DIAGNOSIS, 
PATHOLOGY, AND TREATMENT In one 

octavo volume, leather, of 600 pages. -$1 50. 

COLOMBAT DE L'ISERE ON THE DISEASES 
OF FEMALES, and on the special Hygiene of 
their Sex. Translated, with many Notes and Ad- 
ditions, by C. D. Meigs, M. D. Second edition, 
revised and improved. In one large volume, oc- 
tavo, leather, with numerous wood-cuts. pp. 720. 
$3 50. 



CARSON (JOSEPH), M. D., 

Professor of Materia Medica and Pharmacy in the University of Pennsylvania. 

SYNOPSIS OP THE COURSE OF LECTURES ON MATERIA MEDICA 

AND PHARMACY, delivered in the University of Pennsylvania. Second and revised edi- 
tion. In one very neat octavo volume, extra cloth, of 208 pages. $] 50. 



CURLING (T. B.), F. R.S., 

Surgeon to the London Hospital, President of the Hunterian Society, &c. 

A PRACTICAL TREATISE ON DISEASES OP THE TESTIS, SPERMA- 
TIC CORD, AND SCROTUM. Second American, from the second and enlarged English edi- 
tion. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. $2 00. 



AND SCIENTIFIC PUBLICATIONS 



CHURCHILL (FLEETWOOD), M. D., M. R. !. A. 
ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American 

from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis 
Condie, M. D., author of a "Practical Treatise on the Diseases of Children," 6cc. With 194 
illustrations. In one very handsome octavo volume, leather, of nearly 700 large pages. $3 50. 
(Now Ready, October, I860.) 

This work has been so long an established favorite, both as a text-book for the learner and as a 
reliable aid in consultation ior the practitioner, that in presenting a new edition it is only necessary 
to call attention to the very extended improvements which it has received. Having had the benefit 
of two revisions by the author since the last American reprint, it has been materially enlarged, and 
Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been tho- 
rough^' brought up with the latest results of European investigation in all departments of the sci- 
ence and art of obstetrics. The recent date of the last Dublin edition has not left much of novelty 
for the American editor to introduce, but he has endeavored to insert whatever has since appeared, 
together with such matters as his experience has shown him would be desirable for the American 
student, including a large number of illustrations. With the sanction of the author he has added 
in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses," re- 
cently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of 
advantage to the junior practitioner. The result of all these additions is that the work now con- 
tains fully one-half more matter than the last American edition, with nearly one-half more illus- 
trations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred 
pages more than before. 

No effort has been spared to secure an improvement in the mechanical execution of the work 
equal to that which the text has received, and the volume is confidently presented as one of the 
handsome&t that has thus far been laid before the American profession; while the very low price 
at which it is offered should secure for it a place in every lecture-room and on every office table. 



A better book in which to learn these important 
points we have not met than Dr. Churchill's. Every 
page of it is full of instruction ; the opinion of all 
writers of authority is given on questions of diffi- 
culty, as well as the directions and advice of the 
learned autnor himself, to which he adds the result 
of statistical inquiry, putting statistics in their pro- 
per place and giving them their due weight, and no 
more. We have never read a book more free from 
professional jealousy than Dr. Churchill's. It ap- 
pears to be written with the true design of a book on 
medicine, viz : to give all that is known on the sub- 
ject of which he treats, both theoretically and prac- 
tically, and to advance such opinions of his own as 
he believes will benefit medical science, and insure 
the safety of the patient. We have said enough to 
eonvey to the profession that this book of Dr. Chur- 
chill's is admirably suited for a book of reference 
for the practitioner, as well as a text-book for the 
student, and we hope it may be extensively pur- 
chased amongst our readers. To them we most 
stronsjly recommend it. — Dublin Medical Press, 
June 20, 1660. 

To bestow praise on a book that has received such 
marked approbation would be superfluous. We need 
only say, therefore, that if the first edition was 
thought worthy of a favorable reception by the 
medical public, we can confidently affirm that this 
will be found much more so. The lecturer, the 
practitioner, and the student, may all have recourse 
to its pages, and derive from their perusal much in- 
terest and instruction in everything relating to theo- 
retical and practical midwifery. — Dublin Quarterly 
Journal of Medical Science. 

A work of very great merit, and such as we can 
confidently recommend to the study of every obste- 
tric practitioner. — London Medical Gazette. 

This is certainly the most perfect system extant. 
It is the best adapted for the purposes of a text- 
book, and that which he whose necessities confine 
him to one book, should select in preference to all 
others. — Southern Medical and Surgical Journal. 



The most popular work on midwifery ever issued 
from the American press. — Charleston Med. Journal. 

Were we reduced to the necessity of having bat 
one work on midwifery, and permitted to choose, 
we would unhesitatingly take Churchill. — Western 
Med. and Surg. Journal. 

It is impossible to conceive a more useful and. 
slegant manual than Dr. Churchill's Practice of 
Midwifery. — Provincial Medical Journal. 

Certainly, in our opinion, the very best work on 
he subject which exists. — N. Y. Annalist. 

No work holds a higher position, or is more de- 
serving of being placed in the hands of the tyro, 
the advanced student, or the practitioner. — Medical 
Examiner. 

Previous editions, under the editorial supervision 
of Prof. R. M. Huston, have been received with 
marked favor, and they deserved it; but this, re- 
printed from a very late Dublin edition, carefully 
revised and brought up by the author to the present 
time, does present an unusually accurate and able 
exposition of every important particular embraced 
in the department of midwifery. * * The clearness, 
directness, and precision of its teachings, together" 
with the great amount of statistical research which 
its text exhibits, have served to place it already in 
the foremost rank of works in this department of re- 
medial science. — N. O. Med. and Surg. Journal. 

In our opinion, it forms one of the best if not the 
very best text-book and epitome of obstetric science 
which we at present possess in the English lan- 
guage. — Monthly Journal of Medical Science. 

The clearness and precision of style in which it is 
written, and the greatamountof statistical research 
which it contains, have served to place it in the first 
rank of works in this departmentof medical science. 
—N. Y. Journal of Medicine. 

Few treatises will be found better adapted as a 
text-book for the student, or as a manual for the 
frequent consultation of the young practitioner. — 
American Medical Journal. 



by the same author. (Lately Published.) 

ON THE DISEASES OF INFANTS AND CHILDREN. Second American 

Edition, revised and enlarged by the author. Edited, with Note*, by W. V. Keating, M. D. In 
one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. 
In preparing this work a second time for the American profession, the author has spared do 
labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, 
while every portion of the volume has been subjected to a severe scrutiny. The efforts of the 
American editor have been directed to supplying such information relative to matters peculiar 
to this country as might have escaped the attention of the author, and the whole may, there- 
fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- 
rican Profession. By an alteration in the size of the page, these very extensive additions have 
been accommodated without unduly increasing the size of the work. 

BY THE SAME AUTHOR. 

ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- 
CULIAR TO WOMEN. Selected from the writingsof British Authors previous to the cl< 
the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. §2 50. 



10 BLANCHARD & LEA'S MEDICAL 

CHURCHILL (FLEETWOOD), M. D., M. R. I. A., &c 
ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- 
bed. A new American edition, revised by the Author. With Notes and Additions, by D. Fran- 
cis Condie, M. D., author ol " A Practical Treatise on the Diseases of Children." With nume- 
rous illustrations. In one large and handsome octavo volume, leather, of 768 pages. $3 00. 
This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so 
thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely 
brought up to the most recent condition of the subject, while the very handsome series of illustra- 
tions introduced, representing such pathological conditions as can be accurately portrayed, present 
a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- 
peared desirable for the American student have been made by the editor, Dr. Condie, while a 
marked improvement in the mechanical execution keeps pace with the advance in all other respects 
which the volume has undergone, while the price has been kept at the former very moderate rate. 
It comprises, unquestionably, one of the most ex- 1 extent that Dr. Churchill does. His, indeed, is the 



act and comprehensive expositions of the present 
state of medical knowledge in respect to the diseases 
of women that has yet been published. — Am. Journ. 
Med. Sciences, July, 1857. 

This work is the most reliable which we possess 
on this subject; and is deservedly popular with the 
profession. — Charleston Med. Journal, July, 1857. 

We know of no author who deserves that appro- 
bation, on "the diseases of females," to the same 



only thorough treatise we know of on the subject; 
and it may be commended to practitioners and stu- 
dents as a masterpiece in its particular department. 
— Thi Western Journal of Medicine and Surgery. 

Asa comprehensive manual for students, or a 
work of reference for practitioners, it surpasses any 
other that has ever issued on the same subject from 
the British press. — Dublin Quart. Journal. 



DICKSON (S. H.), M. D., 

Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. 

ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- 
peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and 
handsome octavo volume, of 750 pages, leather. $3 75. (Just Issued.) 

The steady demand which has so soon exhausted the first edition of this work, sufficiently shows 
that the author was not mistaken in supposing that a volume of this character was needed — an 
elementary manual of practice, which should present the leading principles of medicine with the 
practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail 
and fruitless speculations, it embodies what is most requisite for the student to learn, and at the 
same time what the active practitioner wants when obliged, in the daily calls of his profession, to 
refresh his memory on special points. The clear and attractive style of the author renders the 
whole easy of comprehension, while his long experience gives to his teachings an authority every- 
where acknowledged. Few physicians, indeed, have had wider opportunities for observation and 
experience, and few, perhaps, have used them to better purpose. As the result of a long life de- 
voted to study and practice, the present edition, revised and brought up to the date of publication, 
will doubtless maintain the reputation already acquired as a condensed and convenient American 
text-book on the Practice of Medicine. 



DRUITT (ROBERT), M.R.C.S., &c. 
THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new 

and revised American from the eighth enlarged and improved London edition. Illustrated with 
four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume, 
leather, of nearly 700 large pages. $3 50. {Now Ready, October, i860.) 

A work which like Drtjitt's Surgery has for so many years maintained the position of a lead- 
ing favorite with all classes of the profession, needs no special recommendation to attract attention 
to a revised edition. It is only necessary to state that the author has spared no pains to keep the 
work up to its well earned reputation of presenting in a small and convenient compass the latest 
condition of every department of surgery, considered both as a science and as an art; and that the 
services of a competent American editor have been employed to introduce whatever novelties may 
have escaped the author's attention, or may prove of service to the American practitioner. As 
several editions have appeared in London since the issue of the last American reprint, the volume 
has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and 
improvement. The extent of these additions may be estimated from the fact that it now contains 
about one- third more matter than the previous American edition, and that notwithstanding the 
adoption of a smaller type, the pages have been increased by about one hundred, while nearly two 
hundred and fifty wood-cuts have been added to the former list of illustrations. 

A marked improvement will also be perceived in the mechanical and artistical execution of the 
work, which, printed in the best style, on new type, and fine paper, leaves little to be desired as 
regards external finish; while at the very low price affixed it will be found one of the cheapest 
volumes accessible to the profession. 

This popular volume, now a most comprehensive i nothing of real practical importance has heen omit- 
work on surgery, has undergone many corrections, ' ted ; it presents a faithful epitome of everything re- 
improvements, and additions, and the principles and j lating t ) surgery up to the present hour. It is de- 
the practice of the art have been brought down to ! servedly a popular manual, both with the student 
the latest record and observation. Of the operations j and practitioner. — London Lancet, Nov. 19, 1859. 
in surgery it is impossible to speak too hiarhly. The ,.,,.... , 

descriptions are so clear and concise, and the illus- I In closing this brief notice, we recommend as cor- 
trations so accurate and numerous, that the student j ^HV 8 f ver Tl . thls most USeful an ? com P rehensive . 
can have no difficulty, with instrument in hand, and ; hand-book. It must prove a vast assistance, not 
bcok by his side, over the dead body, in obtaining on] y tothe student of surgery, but also to the busy 
a proper knowledge and sufficient tact in this much ! practitioner who may not have the leisure to devote 
neglected department of medical education.— British himself to the study of more lengthy volumes.- 






and Foreign Medico-Chirurg . Revieiv, Jan. 1S60. 



London Med. Times and Gazette, Oct. 22, 1859. 



In the present edition the author has entirely re- In a word, this eighth edition of Dr. Druitt's 
written many of the chapters, and has incorporated j Manual of Surgery is all that the surgical student 
the various improvements and additions in modern j or practitioner could desire. — Dublin Quarterly 
surgery. On carefully going over it, we find that J Journal of Med. Sciences, Nov. 1859. 



AND SCIENTIFIC PUBLICATIONS. 



11 



DALTON, JR. (J. C), M . D. 

Professor of Physiology in the College of Physicians, New York. 

A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students 

and Practitioner? of Medicine. With two hundred and fifty-four illustrations on wood. In one 
very beautiful octavo volume, of over 600 pages, extra cloth, $4 00 ; leather, raised bands, $4 25. 
{Just Issued.) 



This system of Physiology, both from the ex- 
cellence of the arrangement studiously observed 
throughout every page, and the clear, lucid, and in- 
structive manner in which each subject is treated, 
promises to form one of the most generally received 
class-books in the English language. It is, in fact, 
a most admirable epitome of all the really important 
discoveries that have al ways been received as incon- 
testable truths, as well as of those which have been 
recently added to our stock of knowledge on this sub- 
ject. We will, however, proceed to give a few ex- 
tracts from the book itself, as a specimen of its style 
and composition, and this, we conceive, will be quite 
sufficient to awaken a general interest in a work 
which is immeasurably superior in its details to the 
majority of those of the same class ti which it be- 
longs. In its purity of style and elegance of com- 
position it m^y safely take its place with the very 
best of our English classics; while in accuracy of 
description it is impossible that it could be surpass 
ed. In every line is beautifully shadowed forth the 
emanations of the polished scholar, whose reflec- 
tions are clothed in a garb as interesting as they are 
impressive; Vvith the one predominant feeling ap- 
pearing to pervade the whole — an anxious desire to 
please and at the same time to instruct. — Dublin 
Quarterly Journ. of Med. Sciences, Nov. 18-59. 

The work before us, however, in our humble judg- 
ment, is precisely what it purports to be, and will 
answer admirably the purpose for which it is in- 
tended. It is par excellence, a. text-book; and the 
best text-book in tl.is department that we have ever 
seen. We have carefully read the book, and speak 
of its merits from a more than cursory perusal. 
Looking back upon the work we have just finished, 
we must say a word concerning the excellence of its 
illustrations. No department is so dependent upon 
good illustrations, and those which keep pace with 
our knowledge of the subject, as that of physiology. 
The wood- cuts in the work before us are the best 
we have ever seen, and, being original, serve to 
illustrate precisely what is desired — Buffalo Med. 
Journal, March, 1859. 

A book of genuine merit like this deserves hearty 
praise before subjecting it to any minute criticism. 
We are not prepared to find any fault with its design 
until we have had more time to appreciate its merits 
as a manual for daily consultation, and to weigh 
its statements and conclusions more deliberately. 
Its excellences we are sure of; its defects we have 
yet to discover. It is a work highly honorable to 



its author ; to his talents, his industry, his training ; 
to the institution with which he is connected, and 
to American science. — Boston Med. and Surgical 
Journal, Feb. 24, 1859. 

A new book and a first rate one ; an original book, 
and one which cannot be too highly appreciated, 
and which we are proud to see emanating from our 
country's press. It is by an author who, though 
young, is considerably famous for physiological re- 
search, and who in this work has erected for him- 
self an enduring monument, a token at once of his 
labor and his success. — Nashville Medical Journal, 
March, 1859. 

Throughout the entire work, the definitions are 
clear and precise, the arrangement admirable, the 
argument briefly and well stated, and the style 
nervous, simple, and concise. Section third, treat- 
ing of Reproduction, is a monograph of unap- 
proached excellence, upon this subject, in the Eng- 
lish tongue. For precision, elegance and force of 
style, exhaustive method and extent of treatment, 
fulness of illustration and weight of personal re- 
search, we know of no American contribution to 
medical science -which surpasses it, and the day is 
far distant when its claims to the respectful atten- 
tion of even the best informed scholars will not be 
cheerfully conceded by all acquainted with its range 
ana depth. — Charleston Med. Journal, May, 1859. 

A new elementary work on Human Physiology 
lifting up its voice in the presence of late and sturdy 
editions of Kirke's, Carpenter's, Todd and Bow- 
man's, to say nothing of Durglison's and Draper's, 
should have something superior in the matter or the 
manner of its utterance in order to win for itself 
deserved attention and a name. That matter and 
that manner, after a candid perusal, we think dis- 
tinguish this work, and we are proud to welcome it 
not merely for its nativity's sake, but for its own 
intrinsic excellence. Its language we find to be 
plain, direct, unambitious, and falling with a just 
conciseness on hypothetical or unsettled questions, 
and yet with sufficient fulness on those living topics 
already understood, or the path to whose solution 
is definitely marked out. It does not speak exhaust- 
ively upon every subject that it notices, but it does 
speak suggestively, experimentally, and to their 
main utilities. Into the subject of Reproduction 
our author plunges with a kind of loving spirit. 
Throughout this interesting and obscure department 
he is a clear and admirable teacher, sometimes a 
brilliant leader.— Am. Med. Monthly, May, 1859. 



DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. 
THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on 

the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women 
and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 
3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. 
*$$.* This work contains ho less than four hundred and eighteen distinct treatises, contributed by 

sixty-eight distinguished physicians, rendering it a complete library of reference for the country 

practitioner. 



The most complete work on Practical Medicine 
extant; or, at least, in our language.— Buffalo 
Medical and Surgical Journal. 

For reference, it is above all price to every prac- 
titioner. — Western Lancet. 

One of the most valuable medical publications of 
the day — as a work of reference it is invaluable. — 
Western Journal of Medicine and Surgery. 

It has been to us, both as learner and teacher, a 
work for ready and frequent reference, one in which 
modern English medicine is exhibited in the most 
advantageous light. — Medical Examiner. 

We rejoice that this work is to be placed within 
the reach of the profession in this country, it being 
unquestionably one of very great value to the prac- 



DEWEES'S COMPREHENSIVE SYSTEM OF 
MIDWIFERY. Illustrated by occasional cases 
and many engravings. Twelfth edition, with the 
author's last improvements and corrections In 
one octavo volume, extra cloth, of (KH) pages. $:>••>(). 

DEWEES'S TREATISE ON THE PHYSICAL 



titioner. This estimate of it has not been formed 
from a hasty examination, but after an intimate ac- 
quaintance derived from frequent consultation of it 
during the past nine or ten years. The editors are 
practitioners of established reputation, ami the list 
of contributors embraces many of the most eminent 
professors and teachers of London, Edinburgh, Dub- 
lin, and Glasgow. It is, indeed, the great merit of 
this work that the principal articles have been fur- 
nished by practitioners who have not only devoted 
especial attention to the diseases about which they 
have written, but have also enjoyed opportunities 
for an extensive practical acquaintance with them, 
and whose reputation carries the assurance o( their 
competency justly to appreciate the opinions f 
others, while it stamps their own doctrines with 
high and just authority. — American Medical Journ. 



AND MEDICAL TREATMENT OF CHILD- 
REN. The last edition. In one volume, octavo. 
extra cloth, 518 pages. $9 80 

DEWEES'S TREATISE ON THE DISEASES 
OF FEMALES. Tenth edition. In one - 
octavo extra cloth, 53'2 pages, with plates 



12 



BLANCHARJi) & LEA'S MEDICAL 



DUNGLISON (ROBLEY), M. D., 

Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. 
NEW AND ENLARGED EDITION. 

MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise 
Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, 
Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, 
&c. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic 
Preparations, &c. With French and other Synonymes. Revised and very greatly enlarged. 
In one very large and handsome octavo volume, of 992 double-columned pages, in small type ; 
strongly bound in leather, with raised bands. Price $4 00. 

Especial care has been devoted in the preparation of this edition to render it in every respect 
worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid 
sale of Fifteen large editions, and the constantly increasing demand, show that "it is regarded by 
the profession as the standard authority. Stimulated by this fact, the author has endeavored in the 
present revision to introduce whatever might be necessary " to make it a satisfactory and desira- 
ble — if not indispensable — lexicon, in which the student may search without disappointment for 
every term that has been legitimated in the nomenclature of the science." To accomplish this, 
large additions have been found requisite, and the extent of the author's labors may be estimated 
from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- 
dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- 
ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size 
of the paere. The medical press, both in this country and in England, has pronounced the work in- 
dispensable to all medical students and practitioners, and the present improved edition will not lose 
that enviable reputation. 

The publishers have endeavored to render the mechanical execution worthy of a volume of such 
universal use in daily reference. The greatest care has been exercised to obtain the typographical 
accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, 
an immense amount of matter is condensed in its thousand ample pages, while the binding will be 
found strong and durable. With all these improvements and enlargements, the price has been kept 
at the former very moderate rate, placmg it within the reach of all. 



This work, the appearance of the fifteenth edition 
of which, it has become oar duty and pleasure to 
announce, is perhaps the most stupendous monument 
of labor and erudition in medical literature. One 
would hardly suppose after constant use of the pre- 
ceding editions, where we have never failed to find 
a sufficiently full explanation of everj medical term, 
that in this edition '•'•about six thousand subjects 
and terms have been added," with a careful revision 
and correction of the entire work. It is only neces- 
sary to announce the advent of this edition to make 
it occupy the place of the preceding one on the table 
of every medical man, as it is without doubt the best 
and most comprehensive work of the kind which has 
ever appeared. — Buffalo Med.Journ., Jan. 1858. 

The work is a monument of patient research, 
skilful judgment, and vast physical labor, that will 
perpetuate the name of the author more effectually 
than any possible device of stone or metal. Dr. 
Dunglison deserves the thanks not only of the Ame- 
rican profession, but of the whole medical world.— 
North A?n. Medico- Chir. Review, Jan. 1858. 

A Medical Dictionary better adapted for the wants 
of the profession than any other with which we are 
acquainted, and of a character which places it far 
above comparison and competition. — Am. Journ. 
Med. Sciences, Jan. 1858. 

We need only say, that the addition of 6,000 new 
terms, with their accompanying definitions, may be 
said to constitute a new work, by itself. We have 
examined the Dictionary attentively, and are most 
happy to pronounce it unrivalled of its kind. The 
erudition displayed, and the extraordinary industry 
which must have been demanded, in its preparation 
and perfection, redound to the lasting credit of its 
author, and have furnished us with a volume indis- 
pensable at the present day, to all who would find 
themselves au niveau with the highest standards of 
medical information. — Boston Medical and Surgical 
Journal, Dec. 31, 1857. 

Good lexicons and encyclopedic works generally, 
are the most labor-saving contrivances which lite- 
rary men enjoy; and the labor which is required to 
produce them in the perfect manner of this example 
is something appalling to contemplate. The author j 



tells us in his preface that he has added about six 
thousand terms and subjects to this edition, which, 
before, was considered universally as the best work 
of the kind in any language. — Silliman > s Journal, 
March, 1858. 

Ke has razed his gigantic structure to the founda- 
tions, and remodelled and reconstructed the entire 
pile. No less than six thousand additional subjects 
and terms are illustrated and analyzed in this new 
edition, swelling the grand aggregate to beyond 
sixty thousand ! Thus is placed before the profes- 
sion a complete and thorough exponent of medical 
terminology, without rival or possibility of rivalry. 
— Nashville Journ. of Med. and Surg., Jan. 1858. 

It is universally acknowledged, we believe, that 
this work is incomparably the best and most com- 
plete Medical Lexicon in the English language. 
The amount of labor which the distinguished author 
has bestowed upon it is truly wonderful, and the 
learning and research displayed in its preparation 
are equally remarkable. Comment and commenda- 
tion are unnecessary, as no one at the present day 
thinks of purchasing any other Medical Dictionary 
than this.— St. Louis Med. and Surg. Journ., Jan. 
1858. 

It is the foundation stone of a good medical libra- 
ry, and should always be included in the first list of 
books purchased by the medical student.— Am. Med. 
Monthly, Jan. 1858. 

A very perfect work of the kind, undoubtedly the 
most perfect in the English language. — Med. and 
Surg. Reporter, Jan. 1858. 

It is now emphatically the Medical Dictionary oi 
the English language, and for it there is no substi- 
tute.— N. H. Med. Journ., Jan. 1858. 

It is scarcely necessary to remark that any medi- 
cal library wanting a copy of Dunglison's Lexicon 
must be imperfect. — Cin. Lancet, Jan. 1858. 

We have ever considered it the best authority pub- 
lished, and the present edition we may safely say has 
no equal in the world. — Peninsular Med. Journal, 
Jan. 1858. 

The most complete authority on the subject to be 
foundin any language. — Va. Med. Journal, Feb. '58. 



BY THE SAME AUTHOR. 

THE PBACTICE OF MEDICINE. A Treatise on Special Pathology and The- 

rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $8 25. 



AND SCIENTIFIC PUBLICATIONS. 



13 



DUNGLISON (ROBLEY), M.D., 
Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. 

HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- 
sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and 
handsomely printed octavo volumes, leather, of about 1500 pages. $7 00. 

In revising this work for its eighth appearance, the author has spared no labor to render it worthy 
a continuance of the very great favor which has been extended to it by the profession. The whole 
contents have been rearranged, and to a great extent remodelled ; the investigations which of late 
years have been so numerous and so important, have been carefully examined and incorporated, 
and the work in every respect has been brought up to a level with the present state of the subject. 
The object of the author has been to render it a concise but comprehensive treatise, containing the 
whole body of physiological science, to which the student and man of science can at all times refer 
with the certainty of finding whatever they are in search of, fully presented in all its aspects ; and 
on no former edition has the author bestowed more labor to secure this result. 

The best work of the kind in the English lan- 
guage. — Silliman's Journal. 

The present edition the author has made a pence t 
mirror of the science as it is at the present hour. 
As a work upon physiology proper, the science of 
the functions performed by the body, the student will 
find it all he wishes. — Nashville Journ. of Med. 

That he has succeeded, most admirably succeeded 
in his purpose, is apparent from the appearance of 
an eighth edition. It is now the great encyclopaedia 
on the subject, and worthy of a place in every phy- 
sician's library. — Western Lancet. 



We believe that it can truly be said , no more com- 
plete repertory of facts upon the subject treated, 
can any where'be found. The author has, moreover, 
that enviable tact at description and that facility 
and ease of expression which render him peculiarly 
acceptable to the casual, or the studious reader. 
This" faculty, so requisite in setting forth many 
graver and less attractive subjects, lends additional 
charms to one always fascinating. — Boston Med. 
and Surg. Journal. 

The most complete and satisfactory system of 
Physiology in the English language.— Amet. Med. 
Journal. 



BY THE SAME AUTHOR. 



(A new edition.) 



GENERAL THERAPEUTICS AND MATERIA MEDIO A: adapted for a 

Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth 
Edition, revised and improved. With one hundred and ninety-three illustrations. In two large 
and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. 



In announcing a new edition of Dr. Dunglison's 
General Therapeutics and Materia JVledica, we have 
no words of commendation to bestow upon a work 
whose merits have been heretofore so often and so 
justly extolled. It must not be supposed, however, 
that the present is a mere reprint of the previous 
edition ; the character of the author for laborious 
research, judicious analysis, and clearness of ex- 
pression, is fully sustained by the numerous addi- 
tions he has made to the work, and the careful re- 
vision to which he has subjected the whole. — N. A. 
Medico-Chit . Review, Jan. 1858. 



The work will, we have little doubt, be bought 
and read by the majority of medical students; its 
size, arrangement, and reliability recommend it to 
all; no one, we venture to predict, will study it 
without profit, and there are few to whom it will 
not be in some measure useful as a work of refer- 
ence. The young practitioner, more especially, will 
find the copious indexes appendtd to this edkion of 
great assistance in the selection and preparation of 
suitable formulas. — Charleston Med. Journ. and Re- 
view. Jan. 1858. 



BY the same author. (A new Edition.) 

NEW REMEDIES, WITH FORMULA FOR THEIR PREPARATION AND 

ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo 

volume, leather, of 770 pages. $3 75. 

Another edition of the " New Remedies" having been called for, the author has endeavored to 
add everything of moment that has appeared since the publication of the last edition. 

The articles treated of in the former editions will be found to have undergone considerable ex- 
pansion in this, in order that the author might be enabled to introduce, as far as practicable, the 
results of the subsequent experience of others, as well as of his own observation and reflection ; 
and to make the work still more deserving of the extended circulation with which the preceding 
editions have been favored by the profession. By an enlargement of the page, the numerous addi- 
tions have been incorporated without greatly increasing the bulk of the volume. — Preface. 



One of the most useful of the author's works. — 
Southern Medical and Surgical Journal. 

This elaborate and useful volume should be 
found in every medical library, for as a book of re- 
ference, for physicians, it is unsurpassed by any 
other work in existence, and the double index for 
diseases and for remedies, will be found greatly to 
enhance its value. — New York Med. Gazette. 



The great learning of the author, and his remark- 
able industry in pushing his researches into every 
source whence information is derivable, have enabled 
him to tlirow together an extensive mass of facts 
and statements, accompanied by full reference to 
authorities; which last feature renders the work 
practically valuable to investigators who desire t« 
examine the original papers. — The American Journal 
| of Pharmacy. 



ELLIS (BENJAMIN), M . D. 

THE MEDICAL FORMULARY : being a Collection of Prescriptions, derived 
from the writings and practice of many of the most eminent physicians of America and Europe. 
Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added 
an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The 
whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, 
revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the 
Philadelphia College cf Pharmacy. In one neat octavo volume, extra cloth, of 296 pages. SI 75. 



14 



BLANCHARD & LEA'S MEDICAL 



ERSCHSEN (JOHN), 

Professor of Surgery in University College, London, &c. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical 

Injuries, Diseases, and Operations. New and improved American, from the second enlarged 

and carefully revised London edition. Illustrated with over four hundred engravings on wood. 

In one large and handsome octavo volume, of one thousand closely printed pages, leather, 

raised bands. $4 50. (Just Issued.) 

The very distinguished favor with which this work has been received on both sides of the Atlan- 
tic has stimulated the author to render it even more worthy of the position which it has so rapidly 
attained as a standard authority. Every portion has been carefully revised, numerous additions 
have been made, and the most watchful care has been exercised to render it a complete exponent 
of the most advanced condition of surgical science. In this manner the work has been enlarged by 
about a hundred pages, while the series of engravings has been increased by more than a hundred, 
rendering it one of the most thoroughly illustrated volumes before the profession. The additions of 
the author having rendered unnecessary most of the notes of the former American editor, but little 
has been added in this country; some few notes and occasional illustrations have, however, been 
introduced to elucidate American modes of practice. 



It is, in our humble judgment, decidedly the best 
book of the kind in the English language. Strange 
that just such books are notofiener produced by pub- 
lic teachers of surgery in litis country and Great 
Britain. Indeed, it is a maiter of great astonishment, 
but no less true than astonishing, that of the many 
works on surgery republished in this country within 
the last fifteen or twenty years as text-books for 
medical students, this is the only one that even ap- 
proximates to the fulfilment of the peculiar wants of 
youngmen jusi enternigupon the study of this branch 
of the profession. — Western Jour .of Med. and Surgery. 

Its value is greatly enhanced by a very copious 
well-arranged index. We regard this as one of the 
most valuable contributions to modern surgery. To 
one entering his novitiate of practice, we regard it 
the most serviceable guide which he can consult. He 
will find a fulness of detail leading him through every 



step of the operation, and not deserting him until the 
final issue of the case is decided. — Sethoscope. 

Embracing, as will be perceived, the whole surgi- 
cal domain, and each division of itself almost com- 
plete and perfect, each chapter full and explicit, each 
subject faithfully exhibited, we can only express om 
estimate of it in the aggregate. We consider it an 
excellent contribution to surgery, as probably the 
best single volume now extant on 'the subject, and 
with great pleasure we add it to our text-books. — 
Nashville Journal of Medicine and Surgery. 

Prof. Erichsen's work, for its size, has not been 
surpassed; his nine hundred and eight pages, pro- 
fusely illustrated, are rich in physiological, patholo- 
gical, and operative suggestions, doctrines, details, 
and processes ; and will prove a reliable resource 
for information, both to physician and surgeon, in the 
hour of peril.— N. O. Med. and Surg. Journal. 



FLINT (AUSTIN), M. D., 

Professor of the Theory and Practice of Medicine in the University of Louisville, &e. 

PHYSICAL EXPLORATION AND DIAGNOSIS OP DISEASES AFFECT- 
ING THE RESPIRATOPvY ORGANS. In one large and handsome octavo volume, extra 
cloth, 636 pages. $3 00. 

We regard it, in point both of arrangement and of A work of original observation of thehighestmerit. 
the marked ability of its treatment of the subjects, We recommend the treatise to every one who wishes 
as destined to take the first rank in works of this to become a correct auscultator. Based to a very 
class. So far as our information extends.it has at large extent upon cases numerically examined, it 
present no equal. To the practitioner, as well as carries the evidence of earful study and discrimina- 
fche student, it will be invaluable in clearing up the tion upon every page. It does credit to the author, 
diagnosis of doubtful cases, and in shedding light and, through him, to the profession in this country' 
upon difficult phenomena. — Buffalo Med. Journal. It is, what we cannot call every book upon aii3cui- 

I tation, a readable book. — Am. Jour. Med. Sciences. 

BY the same author. (Now Ready.) 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND 

TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 
500 pages, extra cloth. $2 75. 



We do no* know that Dr. Flint has written any- 
thing which is not first rate; but this, his latest con- 
tribution to medical literature, in our opinion, sur- 
passes all the others. The work is most comprehen- 
sive in its scope, and most sound in the views it, enun- 
ciates. The descriptions are clear and methodical; 
the statements are substantiated by facts, and are 
made with such simplicity and sincerity, that with- 
out them they would carry conviction. The style 
is admirably clear, direct, and free from dryness 
With Dr. Walshe's excellent treatise before us, we 
have no hesitation in saying that Dr. Flint's book is 
the best work on the heart in the English language. 
— Boston Med. and Surg. Journal, Dec. 15, 1859. 

We have thus endeavored to present our readers 
with a fair analysis uf this remarkable work. Pre- 
ferring to employ the very words of thedistinguished 
author, wherever it was possible, we have essayed 
to condense into the briefest spacea general view of 
his observations and suggestions, and to direct the 
attention of our brethren to the abounding stores of 
valuable matter here collected and arranged for their 
use and instruction. No medical library will here- 
after be considered complete without this volume ; 
and we trust it will promptly find its way into the 
hands of every Ameiican student and physician. — 
N. Am. Med. Chir. Review, Jan. 1860. 

This last work of Prof. Flint will add much to 
his previous well-earned celebrity, as a writer of 
great force and beauty, and, with his previous work, 
places him at the head of American writers upon 



diseases of the chest. We have adopted' his work 
upon the heaTt as a text-book, believing it to be 
more valuable for that purpose than any work of the 
kind that has yet appeared. — Nashville Med. Journ., 
Dec. 1859. 

With more than pleasure do we hail the advent of 
this work, for it fills a wide gap on the list of text- 
books for our schools, and is, for the practitioner, 
the most valuable practical work of its kind. — N. O. 
Med. News, Nov. 1859. 

In regard to the merits of the work, we have no 
hesitation in pronouncing it full, accurate, and ju- 
dicious. Considering the presmt state of science, 
such a work was much needed. It should be in the 
hands of every practitioner. — Chicago Med. Journal, 
April, 1860. 

But these are very trivial spots, and in nowise 
prevent us from declaring our most hearty approval 
of the author's ability, industry, and conscientious- 
ness. — Dublin Quarterly Journal of Med. Sciences, 
Feb. 1860. 

He has labored on with the same industry and care, 
and his place among the first authors of our country 
is becoming fully established. To this end, the work 
whose title is given above, contributes in no small 
degree. Our spa^e will not admit of En extended 
analysis, and we will close this Drief notice by 
commending it without reserve to every class of 
readers in the profession. — Peninsular Med. Journ., 
Feb. 1860. 



AND SCIENTIFIC PUBLICATIONS. 



15 



FOWNES (GEORGE), PH. D., &c. 
A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. 

From the seventh revised and corrected London edition. With one hundred and ninety-seven 

illustrations. Edited by Robert Bridges, M. D. In one large royal 12mo. volume, of fc)00 

pages. In leather, $1 6-5; extra cloth, $1 50. (Just Is sited.) 

The death of the author having- placed the editorial care of this work in the practised hands of 
Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience 
could suggest to keep it on a level with the rapid advance of chemical science. The additions 
requisite to this purpose have necessitated an enlargement of the page, notwithstanding which the 
work has been increased by about fifty pages. At the same time every care has been used to 
maintain its distinctive character as a condensed manual for the student, divested of all unnecessary 
detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- 
ment of Organic Chemistry, which has made such rapid progress within the last few years, but 
yet equal attention has been bestowed on the other branches of the subject — Chemical Physics and 
Inorganic Chemistry — to present all investigations and discoveries of importance, and to keep up 
the reputation of the volume as a complete manual of the whole science, admirably adapted for the 
learner. By the use of a small but exceedingly clear type the matter of a large octavo is compressed 
within the convenient and portable limits of a moderate sized duodecimo, and at the very low price 
affixed, it is offered as one of the cheapest volumes before the profession. 



Dr. Fownes' excellent work has been universally 
recognized everywhere in nis own and this country, 
as the best elementary treatise on chemistry in the 
English tongue, and is very generally adopted, we 
believe, as the standard text- book in all < ur colleges, 
both literary and scientific. — Charleston Med. Journ. 
and Review, Sept. 1859. 

A standard manual, which has long enjoyed the 
reputation of embodying much knowledge in a small 
space. The author has achieved the difficult task of 
condensation with masterly tact. His book is con- 
cise without being dry, and brief without being too 
dogmatical or general. — Virginia Med. and Surgical 
Journal. 



The work of Dr. Fownes has long been before 
the public, and its merits have been fully appreci- 
ated as the best text-book on chemistry now in 
existence. We do not, of course, place it in a rank 
superior to the works of Brande, Graham, Turner, 
Gregory, or Gmelin, but we say that, as a work 
for students, it is preferable to any of them. — Lon- 
don Journal of Medicine. 

A work well adapted to the wants of the student 
It is an excellent exposition of the chief doctrines 
and facts of modern chemistry. The size of the work, 
and still more the condensed yet perspicuous style 
in which it is written, absolve it from the charges 
very properly urged against most manuals termed 
I popular. — Edinburgh Journal of Medical Science. 



FISKE FUND PRIZE ESSAYS. — THE EF- 
FECTS OF CLIMATE ON TUBERCULOUS 
DISEASE. By Edwin Lee, M.R. C. S , London, 
and THE INFLUENCE OF PREGNANCY ON 
THE DEVELOPMENT OF TUBERCLES By 



Edward Warren, M. D , of Edenton, N. C. To- 
gether in one neat 8vo volume, extra cloth. $1 00. 
FRICK ON RENAL AFFECTIONS; their Diag- 
nosis and Pathology. With illustrations. One 
volume, royal 12mo., extra cloth. 75 cents 



FERGUSSON (WILL3AM), F. R. S., 
Professor of Surgery in King's College, London, &c. 

A SYSTEM OF PRACTICAL SURGrEKY. Fourth American, from the third 

and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 
pages, with. 393 handsome illustrations, leather. $3 00. 



GRAHAM (THOMAS), F. R. S. 

THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applica- 
tions of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert 
Bridges, M. D. Complete in one large and handsome octavo volume, of over 800 very large 
pages, with two hundred and thirty-two wood-cuts, extra cloth. $4 00. 
%.*$. Part II., completing the work from p. 431 to end, with. Index, Title Matter, &c, may be 

had separate, cloth backs and paper sides. Price $2 50. 
From Prof. E. N. Horsford, Harvard College. 
It has, in its earlier and less perfect editions, been 

famil ; ar to me, and the excellence of its plan and 

the clearness and completeness of its discussions, 

have long been my admiration. 



No reader of English works on this science can 



aiford to be without this edition of Prof. Graham's 
Elements. — Silliman's Journal, March, 1S5S. 

From Prof. Wolcott Grikbs, N. Y. Free Academy. 

The work is an admirable one in all respects, and 
its republication here cannot fail to exert a positive 
influence upon the progress of science in this country. 



GRIFFJTH (ROBERT E.), M. D., &c. 

A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- 

ministering Officinal and other Medicines. The whole adapted to Physicians and Pharfnaceu. 
lists. Second Edition, thoroughly revised, with numerous additions", by Robert P. Thomas. 
M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and 
handsome octavo volume, extra cloth, of 650 pages, double columns. S3 00"; or in sheep. S3 25. 



It was a work requiring much perseverance, and 
when published was looked upon as by far the best 
work of its kind that had issued from the American 
press. Prof Thomas has certainly "improved," as 
well as added to this Formulary, and has rendered it 
additionally deserving of the confidence of pharma- 
ceutists and physicians.— Am. Journal of Pharmacy. 

We are happy to announce a new and improved 
edition of this, one of the most valuable and useful 
works that have emanated from an American pen. 
It would do credit to any country, and will be found 
of daily usefulness to practitioners of medicine; it is 
better adapted to their purposes than the dispensato- 
ries. — Southern Med. and Surg. Journal. 

It is one of the most useful books a country practi 
tioner can possibly have. — Medical Chronicle. 



This is a work of six hundred and hay one pages, 
embracing all on the subject of preparing and admi- 
nistering medicines that can be desired by the physi- 
cian and pharmaceutist.— Western Lancet. 

The amoun t of useful, e very-day matter. for a prac- 
ticing physician, is really immense. — Bosta 
and Surg. Journal. 

This edition has been greatly improved by the re- 
vision and ample additions of Dl Thomas, and is 
now, we believe, one o( the mosi complete works 
of its kind in any language. The additions amount 
to about seventy pages, ana no effort has been spared 
to include in them all the recent improvements. A 
work of this kind appears la us indispensable to the 
physician, and there is none «ve can mere co 
recommend. — N. V. Journal of Medicint. 



16 



BLANCHARB & LEA'S MEDICAL 



GROSS (SAMUEL D.), M. D., 

Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. 
Just Issued. 

A SYSTEM OP SURGERY : Pathological, Diagnostic, Therapeutic, and Opera- 
tive. Illustrated by Nine Hundred and Thirty-six Engravings. In two large and beautifully 



printed octavo volumes, of nearly twenty-four hundred* pages 
raised bands. Price $12. 

From the Author's Preface. 



strongly bound in leather, with 



" The object of this work is to furnish a systematic and comprehensive treatise on the science and 
practice of surgery, considered in the broadest sense; one that shall serve the practitioner as a 
faithful and available guide in his daily routine of duty. It has been too much the custom of mod- 
ern writers on this department of the healing art to omit certain topics altogether, and to speak oi 
others at undue length, evidently assuming that their readers could readily supply the deficiencies 
from other sources, or that what has been thus slighted is of no particular practical value. My aim 
has been to embrace the whole domain of surgery, and to allot to every subject its legitimate claim 
to notice in the great family of external diseases and accidents. How far this object has been accom- 
plished, it is not for me to determine. It may safely be affirmed, however, that there is no topic, 
properly appertaining to surgery, that will not be found to be discussed, to a greater or less extent, 
in these volumes. If a larger space than is customary has been devoted to the consideration of 
inflammation and its results, or the great principles of surgery, it is because of the conviction, 
grounded upon long and close observation, that there are no subjects so little understood by the 
general practitioner. Special attention has also been bestowed upon the discrimination of diseases; 
and an elaborate chapter has been introduced on general diagnosis." 

That these intentions have been carried out in the fullest and most elaborate manner is sufficiently 
shown by the great extent of the work, and the length of time during which the author has been 
concentrating on the task his studies and his experience, guided by the knowledge which twenty 
years of lecturing on surgical topics have given him of the wants of the profession. 

Of Dr. Gross's treatise on Surgery we can say 
no more than that it is the most elaborate and com- 
plete work on this branch of the healing art which 
has ever been published in any country. A sys- 
tematic work, it admits of no analytical review ; 
but, did our space permit, we should gladly give 
some extracts from it, to enable our readers to judge 
of the classical style of the author, and the exhaust- 
ing way in which each subject is treated. — Dublin 
Quarterly Journal of Med. Science, Nov. 1859. 

The work is so superior to its predecessors in 
matter and extent, as well as in illustrations and 
style of publication, that we can honestly recom- 
mend it as the best work of the kind to be taken 
home by the young practitioner. — Am. Med. Journ., 
Jan. 1360. 

The treatise of Prof. Gross is not, therefore, a 
mere text-book for undergraduates, but a systema- 
tic record of more than thirty years' experience, 
reading, and reflection by a man of observation, 
sound judgment, and i are practical tact, and as such 
deserves to take rank with the renowned produc- 
tions of a similar cha r acter,by Vidal and Boyer, of 
France, or those of Chelius, Blasius, and Langen- 
becU, of Germany. Hence, we do not hesitate to 
express the opinion that it will speedily take the 
same elevated position in regard to surgery that has 
been given by common consent to the masterly work 
of Pereira in Materia Medica, or to Todd and Bow- 
man in Physiology. — N. O. Med. omd Surg. Journal, 
Jan. 1560. 



At present, however, our object is not to review 
the work (this we purpose doing hereafter), but 
simply to announce its appeal ance, that m the 
meantime oar readers may procure and examine it 
for themselves. But even this much we cannot do 
without expressing the opinion that, in putting forth 
these two volumes, Dr. Gross has reared for him- 
self a lasting monument to his skill as a surgeon, 
and to his industry and learning as an author. — St. 
Louis Med. and Surg. Journal, Nov. 1859. 

With pleasure we record the comp^tion of this 
long-anticipsted work. The reputation which the 
author has for many years sustained, both as a sur- 
geon and as a writer, had prepared us to expect a 
treatise of great excellence and originality; but we 
confess we were by no means prepared for the work 
which is before us — the most complete treatise upon 
surgery ever published, either in this or any other 
country, and we might, perhaps, safely say, the 
most original. There is no subject belonging pro- 
perly to surgery which has not received from the 
authoiadue share of attention. Dr. Gross has sup- 
plied a want in surgical literature which has long 
been felt by practitioners; he has furnished us with 
a complete practical treatise upon surgery in all its 
departments. As Annencins, we are proud of the 
achievement; as surgeons, we are most sincerely 
thankful to him for his extraord nary labors in our 
behalf. — N. Y Monthly Review and Buffalo Med. 
Journal, Oct. 1850. 



BY THE SAME AUTHOR. 

ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly 

revised and greatly improved. In one large and very handsome octavo volume, with about three 
hundred and fifty beautiful illustrations, of which a large number are from original drawings. 
Price in extra cloth, $4 75; leather, raised bands, $5 25. (Lately Published.) 
The very rapid advances in the Science of Pathological Anatomy during the last few years have 
rendered essential a thorough modification of this work, with a view of making it a correct expo- 
nent of the present state of the subject. The very careful manner in which this task has been 
executed, and the amount of alteration which it has undergone, have enabled the author to say that 
" with the many changes and improvements now introduced, the work may be regarded almost as 
a new treatise," while the efforts of the author have been seconded as regards the mechanical 
execution of the volume, rendering it one of the handsomest productions of the American press. 

We most sincerely congratulate the author on the We have been favorably impressed with the gene- 
successful manner in which he has accomplished his 
proposed object. His book is most admirably cal- 
culated to fill up a blank which has long been felt to 
exist in this department of medical literature, and 
as such must, become very widely circulated amongst 
all classes of the profession. — Dublin Quarterly 
Journ. of Med. Science, Nov. 1857. 



ral manner in which Dr. Gross has execu ted his task 
of affording a comprehensive digest of the present 
state of the literature of Pathological Anatomy, and 
have much pleasure in recommending his work to 
our readers, as we believe one well deserving of 
diligent perusal and careful study. — Montreal Med. 
Chron., Sept. 1857. 

BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- 

SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. $2 75. 



AND SCIENTIFIC PUBLICATIONS. 



17 



GROSS (SAMUEL D.), M . D., 

Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND 

MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND 
THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- 
four illustrations. In one large and very handsome octavo volume, of over nine hundred pages. 
In leather, raised bands, $5 25 ; extra cloth, $4 75. 



Philosophical in its design, methodical in its ar- 
rangement, ample and sound in its practical details, 
it may in truth be said to leave scarcely anything to 
be desired on so important a subject. — Boston Med. 
and Surg Journal. 

Whoever will peruse the vast amount of valuable 
practical information it contains, will, we think, 



agree with us, that there is no work in the English 
language which can make any just pretensions to 
be its equal. — N. Y. Journal of Medicine. 

A volume replete with truths and principles of the 
utmost value in the investigation of these diseases. - 
American Medical Journal. 



GRAY (HENRY), F. R. S., 
Lecturer on Anatomy at St. George's Hospital, London, Sec. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. Y. 

Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissections jointly 
by the Author and Dr. Carter. In one magnificent imperial ocfavo volume, of nearly 800 
pages, with 363 large and elaborate engravings on wood. Price in extra cloth, $6 25; leather 
raised bands, $7 00. {Just Issued.) 

The author has endeavored in this work to cover a more extended range of subjects than is 
customary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference tor the active practitioner. The 
engravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of figures 
of reference with descriptions at the foot. They thus form a complete and splendid series, which 
will greatly assist the student ia obtaining a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recalling the details 
of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with a thorough 
treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use 
to all physicians who receive students in their offices, relieving both preceptor and pupil of much 
labor in laying the groundwork of a thorough medical education. 



The work before us is one entitled to the highest 
praise, ?nd we accordingly welcome it as a valu- 
able addition to medical literature. Intermediate 
in fulness of detail between the treatises of S.rar 
pey and of Wilson, its characteristic merit lies in 
the number and excellence of the engravings it 
contains. Most of these are original, of much 
larger than ordinary size, and admirably executed. 
The various parts are also lettered after the plan 
adopted in Roiden's Osteology. It would be diffi- 
cult to over-estimate the advantages offered by this 
mode of piciorial illustration. Bones, ligaments, 
muscles, bloodvessels, and nerves are each in turn 
fiffared, and marked with their appropriate names ; 
thus enabl ing the student to c( mprehend, at a glance, 
what would otherwise often be ignored, or at any 
rate, acquired only by prolonged and irksome ap- 
plication. In conclusion, we heartily commend the 
work of Mr. Gray to the attention of the medical 
profession, feeling certain that it should be regarded 
as one of the most valuable contributions ever made 
to educational literature. — N. Y. Monthly Review. 
Dec. 1859. 

In this view, we regard the work of Mr. Gray as 
far better adapted to the wants of the profession, 
and especially of the student, than any treatise on 
anatomy yet published in this country. 1 1 is destined, 
we believe, to supersede ill others, both as a manual 
of dissections, and a standard of reference to the 
student of general or relative anatomy. — A r . 1". 
Journal of Medicine, Nov. 1859. 

This is by all comparison the most excellent work 
on Anatomy extant. It is just the thing that has 
been long desired by the profession. With such a 
jruide as this, the student of anatomy, the practi- 
tioner of medicine, and the surgical devotee have 
all a newer, clearer, and more radiant light thrown 
upon the intricacies and mysteries of this wonder- 
ful science, and are thus enabled to accomplish re- 
sults which hitherto seemed possible only to the 
specialist. The plates, which are copied from re- 
cent dissections, are so well executed, that the most 
superficial observer cannot fail to perceive the posi- 
tions, relations, and distinctive features of the vari- 
ous parts, and to take in more of anatomy at a glance, 
than by many long hours of diligent study over the 
most erudite treatise, or, perhaps, at the dissecting 
table itself. — Med. Journ. of N. Carolina, Oct. 1859. 

For this truly admirable work the profession is 
indebted to the distinguished author of ''Cray on 
the Spleen." The vacancy it fills has been long fell 



to exist in this country. Mr. Gray writes through- 
out with both branches of his subject in view. His 
description of each particular part is followed by a 
notice of its relations to tie parts with which it is 
connected, and this, too, sufficiently ample for all 
the purposes of the operative surgeon. After de- 
scribing the bones and muscles, he gives a concise 
statement of the fractures to which the bones of 
the extremities are most liable, together with the 
amount and direction of the displacement to which 
the fragments are subjected by muscular action. 
The section on arteries is remarkably full and ac- 
curate. Not only is the surgical anatomy given to 
every important vessel, with directions for its liga- 
tion, but at the end of the description of each arte- 
rial trunk we have a useful summary of the irregu- 
larities which may occur in its origin, course, and 
termination. — N. A. Med. Chir. Review, Mar. 1859. 

Mr. Gray's book, in excellency of arrangement 
and completeness of execution, exceeds any work 
on anatomy hitherto published in the English lan- 
guage, affording a complete view of the structure of 
the human body, with especial reference to practical 
surgery. Thus the volume constitutes a perfect oook 
of reference for the practitioner, demanding a place 
in even the most limited library of the physician or 
surgeon, and a work of necessity for the student to 
fix in his mind what he has learned by the dissecting 
knife from the book of nature. — The Dublin Quar- 
terly Journal of Med. Sciences, Nov. 1808. 

In our judgment, the mode of illustration adopted 
in the present volume cannot but present many ad- 
vantages to the student of anatomy. To the zealous 
disciple of Vesalius, earnestly desirous of real im- 
provement, the book will certainly be o( immense 
value; but, at the same time, we must also confess 
that, to those simply desirous o( lt cramming' 3 it 
will be an undoubted godsend. The peculiar value 
of Mr. Gray's mode of illustration is nowhere more 
markedly evident than in the chapter on osteology, 
and especially in those portions which treat of the 
bones of the head and oi thnr development. The 
study of these parts is thus made one of comparative 
ease, if not of positive pleasure ; and those bugbears 
of the student, the temporal and sphenoid bones, are 
shorn of half their terrors. It is. in our estimation, 
an admirable and complete text-book for the student, 
and a useful work oi reference for the practitioner; 
its pictorial character forming a novel elemi 
which we have alread] sufficiently allude.' 
Journ. Med. >>/., July, 1859. 



IS 



BLANCHARD & LEA'S MEDICAL 



GIBSON'S INSTITUTES AND PRACTICE OF 
SURGERY. Eighth edition, improved and al- 
tered. With thirty-four plates. In two handsome 
octavo volumes, containing about 1,000 pages, 
leather, raised bandi. S6 50. 

GARDNER'S MEDICAL CHEMISTRY, for the 
use of Students and the Profession. In one royal 
12mo. vol., cloth, pp. 396, with wood-cuts. SI. 

GLUGE'S ATLAS OF PATHOLOGICAL HIS- 
TOLOGY. Translated, with Notes and Addi- 



tions, by Joseph Leidy, M. D. In one volume, 
very large imperial quarto, extra cloth, wit"i320 
copper-plate figures, plain and colored, So 00. 

HUGHES' INTRODUCTION TO THE PRAC- 
TICE OF AUSCULTATION ANJJ OTHER 
MODES OF PHYSICAL DIAGNOSIS IN DIS- 
EASES OF THE LUNGS AND HEART. Se- 
cond edition 1 vol. royal l'imo., ex. cloth, pp. 
304. SI 00, 



HAMILTON (FRANK H.), M. D., 

Professor of Surgery in the University of Buffalo, &c. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. In 

one large and handsome octavo volume, of over 750 pages, with 2S9 illustrations. $4 25. (Now 

Ready, January, 1S60.) 

This is a valuable contribution to the surgery of i illustrated, which will be a desideratum for those 
most important affections, and is the more welcome, | practitioners who cannot conveniently see the mo- 
inasmuch as at the present time we do not possess j dels applied. — New York Med. Press, Feb. 4, 1S60. 
a single complete treatise on Fractures and Dislo- I We reffard this work as an honor not onl to itg 
cations in the English language. It has remained for author bnt t0 the profession of our country. Were 
°!"'f ™ eiiCa u^ brother to pr^dujie a comp lete treatise | we t0 rev iewit thoroughly, we could not convey to 

the mind of ihe reader more forcibly our honest 



upon the subject, and bring together in a convenient 

form those alterations and improvements that have 

been made from time to time in the treatment of these 

affections. One great and valuable featuie in the 

work before us is the fact that it comprises all the 

improvements introduced into the practice of both 

English and American surgery, and though far from 

omitting mention of our continental neighbors, the 

author by no means encourages the notion — but too 

prevalent in some quarters— that nothing is good 

unless imported from France or Germany. The 

latter half of the work is devoted to the considera- 
tion of the various dislocations and their appropri 

are treatment, and its me 

the preceding portion. — Th„ ~ 

1S60 tamly be veiy large in this country 

T ' pate its eliciting much attention in Europe. — Nash- 

It is emphatically the book upon the subjects of viUe Medical Record, Mar. 1SG0. 

which it treats, and we cannot doubt that it will „ , ,, , ,, 

continue so to be for an indefinite period of time. . Eve , r / W eon i young and old, should possess 

When we say, however, that we believe it will at himself of it, and give it a careful perusal, m doing 

once take its place as the best book for consultation **«£ he ™» be 7 "f 1 >' 1 re ( , ^'~ * 

by the practitioner; and that it will form the most and Sur S- Journal, March, 1S60. 

complete, available, and reliable guide in emergen- Dr. Hamilton is fortunate in having succeeded in 



opinion expressed in the few words— we think it the 
best book of its kind extant. Every man interested 
in surgery will soon have this work on his desk. 
He who does not, will be the loser. — New Orleans 
Medical News, March, I860. 

Now that it is before us, we feel bound to say that 

much as was expected from it, and onerous as was 

the undertaking, it has surpassed expectation, and 

achieved more than was pledged in its behalf; for 

its title does not express in full the richness of its 

contents. On the whole, we are prouder of this 

■rlu^fuVl^ equal to that'of work than of any which has for years emanated 

The London Lancet, Max 5, from the American medical press; its sale will cer- 

' J ' tamlv be veiy large in this country, and we antici- 



cies of every nature connected with its subjects 
also that the student of surgery may make it his text- 
book with entire confidence, and with pleasure also, 
from its agreeable and easy style — we think our own 
opinion may be gathered as to its value. — Boston 
Medical and Surgical Journal, March 1, I860. 

The work is concise, judicious, and accurate, and 
adapted to the wants of the student, practitioner, 
and investigator, honorable to the author and to the 
profession. — Chicago Med. Journal, March, 1860, 

We venture to say that this is not alone the only 
complete treatise on the subject in the language, 
but the best and most practical we have ever read. 



filling the void, so long felt, with what cannot fail 
to be at once accepted as a model monograph in some 
respects, and a work of classical authority. We 
sincerely congratulate the profession of the United 
States on the appearance of such a publication from 
one of their number. We have reason to be proud 
of it as an original work, both in a literary and sci- 
entific point of view, and to esteem it as a valuable 
guide in a most difficult and important branch of 
study and practice. On every account, therefore, 
we hope that it may soon be widely known abroad 
as an evidence of genuine progress on this side of 
the Atlantic, and further, that it may be still more 
widely known at home as an authoritative teacher 



The arrangement is simple and systematic, the die- from which every one may profitably learn, and 

tion clear and graplvc, and the illustrations nume- affording an example of honest, well-directed, and 

rous and remarkable for accuracy of delineation, untiring industry in authorship which every surgeon 

The various mechanical appliances are faithfully may emulate.- Am. Med. Journal, April, 1860. 



HOBLYN (RICHARD D.), M. D. 
A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE 

COLLATERAL SCIENCES. A new American edition. Revised, with numerous Additions, 
by Isaac Hays, M. D., editor of the " American Journal of the Medical Sciences." In one large 
royal 12mo. volume, leather, of over 500 double columned pages. SI 50. 
To both practitioner and student, we recommend use ; embracing every department of medical science 

this dictionary as being convenient in size, accurate ] down to the very latest date. — Western Lancet. 

in definition, and sufficiently full and complete for Hoblyn's Dictionary has long been a favorite with 

ordinary consultation.— Charleston Med. Journ. us It is tne Dest oook f definitions we have, and 

We know of no dictionary better arranged and ought always to be upon the student's table. — 

adapted. It isnotencumbered with theobsoleteterm3 Southern Med. and Surg . Journal . 

of a bygone age, but it contains all that are now in | 



HOLLAND'S MEDICAL NOTES AND RE- 
FLECTIONS. From the third London edition. 
In one handsome octavo volume, extra clo'h. $3. 

HORNER'S SPECIAL ANATOMY" AND HIS- 



TOLOGY. Eighth edition. Extensively revised 
and modified. In two large octavo volumes, ex- 
tra cloth, of more than 1000 pages, with over 300 
illustrations. S6 00. 



HABERSHON (S. O.), M. D,, 
Assistant Physician to and Lecturer on Materia Medica and Therapeutics at Guv's Hospital, &c. 

PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES 

OF THE ALIMENTARY CANAL, (ESOPHAGUS, STOMACH, CAECUM, AND INTES- 
TINES. With illustrations on wood. In one handsome octavo volume of 312 pages, extra 
cloth SI 75. (Now Ready.) 



AND SCIENTIFIC PUBLICATIONS. 19 

HODGE (HUGH L.), M. D., 

Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, Sec. 

ON DISEASES PECULIAR TO WOMEN, including Displacements of the 
Uterus. With original illustrations. In one beautifully printed octavo volume, of nearly 500 
pages. (Noiv Ready.) 

The profession will look with much interest on a volume embodying the long and extensive ex- 
perience of Professor Hodge on an important branch of practice in which his opportunities for 
investigation have been so extensive. A short summary of the contents will show the scope of 
the work, and the manner in which the subject is presented. It will be seen that, with the excep- 
tion of Displacements of the Uterus, he divides the Diseases peculiar to Women into two great 
constitutional classes — those arising from irritation, and those arising from sedation. 

CONTENTS. 

PART I. Diseases of Irritation. — Chapter I. Nervous Irritation, and its Consequences. — [I. 
Irritable Uterus. — III. Local Symptoms of Irritable Uterus: Menorrhagia and Haemorrhagia; 
Leucorrboea ; Dysmenorrhoea — IV. Local Symptoms of Irritable Uterus; Complications. — V. 
Geneial Symptoms of Irritable Uterus : Cerebrospinal Irritations. — VI. General Symptoms of 
Irritable Uterus. — VII. Progress and Results of Irritable Uterus. — VIII. Causes and Pathology 
of Irritable Diseases — IX. Treatment of Irritable Uterus; Removal or Palliation of the Cau>e. 
— X. Treatment of Irritable Uterus: To Diminish or Destroy the Morbid Irritability — X[. 
Treatment of the Complications of Irritable Uterus. — XII. Treatment of the Complications of 
Irritable Uterus. 

PART II. Displacements of the Uterus. — Chapter I. Natural Position and Supports of the 
Uterus. — II. Varieties of Displacements of the Uterus, and their Causes. — III. Symptoms of 
Displacements of the Uterus. — IV. Treatment of Displacements of the Uterus. — V. Treatment 
of Displacements; Internal Supports. — VI. Treatment of Displacements ; Lever Pessaries. — 
VII. Treatment of the Varieties of Displacements. — VIII. Treatment of Complications of Dis- 
placements of the Uterus. — IX. Treatment of Enlargements and Displacements of the Ovaries, &c. 

PART III. Diseases of Sedation. — Chapter I. Sedation and its Consequences: Organic and 
Nervous Sedation; Passive Congestion ; Reaction; Treatment — II. Sedation of the Uttjrus; 
Amenorrhoea: Sedation of the Uterus from Moral Causes; Sedation of the Uterus from Physical 
Causes. — III. Diagnosis and Treatment of Sedation of the Uterus. 
The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. 



JONES (T. WHARTON), F. R. S., 

Professor of Ophthalmic Medicine and Surgery in University College, London, &c. 

THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE 

AND SURGERY. With one hundred and ten illustrations. Second American from the second 
and revised London edition, with additions by Edward Hartshorne, M.D., Surgeon to Wills' 
Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 50. 



JONES (C. HAND FIELD), F. R. S. s & EDWARD H. SIEVEKING, M.D., 

Assistant Physicians and Lecturers in St. Mary's Hospital, London. 

A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, 

Revised. With three hundred and ninety-seven handsome wood engravings. In one large and 
beautiful octavo volume of nearly 750 pages, leather. $3 75. 



As a concise text-book, containing, in a condensed 
form, a complete outline of what is known in the 
domain of Pathological Anatomy, it is perhaps the 
best work in the English language, its great merit 
consists in its completeness and brevity, and in this 
respect it supplies a great desideratum in our lite- 
rature. Heretofore the student of pathology was 



obliged to glean from a great number of monographs, 
and. 'the field was so extensive that but few cultivated 
it with any degree of success. As a simple work 
of reference, therefore, it is of great value to the 
student of pathological anatomy, and should be in 
every physician's library. — Western Lancet. 



KIRKES (WILLIAM SENHOUSE), M.D., 

Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, Sec. 

A MANUAL OF PHYSIOLOGY. A now American, from the third and 

improved London edition. With two hundred illustrations. In one large and handsome royal 
12mo. volume, leather, pp. 586. $2 00. {Lately Published.) 



This is a new and very much improved edition of 
Dr. Kirkes' well-known Handbook of Physiology. 
It combines conciseness with completeness, and is, 
therefore, admirably adapted for consultation by the 
busy practitioner. — Dublin Quarterly Journal. 

Its excellence is in its compactness, its clearness, 
and its carefully cited authorities. It is the most 
convenient of text-books. These gentlemen, Messrs. 
Kirkes and Paget, have really an immense talent for 
silence, which is not so common or so cheap as prat- 
ing people fancy. They have the sift of telling us 
what we want to know, without thinking it neces- 
sary to tell us all they know. — Boston Med and 
Surg. Journal. 



One of the very best handbooks of Physiology we 
possess— presenting just such an outline of t lie sci- 
ence as the student requires during bis attendance 
upon a course of lectures, or for reference whilst 
preparing for examination.— Am. Medical Journal. 

For the student beginning this study, and the 
practitioner who lias but leisure to refresh his 
memory, this book is invaluable, as it contains all 
that it is important to know, without special details, 
which are read with interest only by those who 
would make a specialty, or desire to possess a criti- 
cal knowledge of the subject. — Charleston Mnd, 
Journal. 



•20 



BLANCHARD & LEA'S MEDICAL 



KNAPP'S TECHNOLOGY ; or, Chemistry applied 
to the Arts and to Manufactures. Edited by Dr. 
Ronalds, Dr. Richaedson, and Prof. W. R. 
Johnson. In two handsome 8vo. vols., with about 
500 wood- engravings. $6 00. 



LAYCOCK'S LECTURES ON THE PRINCI- 
PLES AND METHODS OF MEDICAL OB- 
SERVATION AND RESEARCH. For the Use 

of Advanced Students and Junior Practitioners. 
In one royal 12mo. volume, extra cloth. Price $1. 



LALLEMAND AND WILSON. 
A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND 

TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and edited by 

Henry J McDougall. Third American edition. To which is added ON DISEASES 

OF THE VESICULvE SEMINALES; and their associated organs. With special refer- 
ence to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Marris 
Wilson, M. D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Just Issued.} 

LA ROCHE (R.), M. D., &c. 
YELLOW FEVER, considered in its Historical, Pathological, Etiological, and 
Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia 
from 1699 to 1854, with an examination of the connections between it and the fevers known under 
the same name in other parts of temperate as well as in tropical regions. In two large and 
handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. 

riant and unmanageable disease of modern times, 
has for several years been prevailing in our country 
to a greater extent than ever before; that it is no 
longer confined to either large or small cities, but 
penetrates country villages, plantations, and farm- 
houses ; that it is treated with scarcely better suc- 
cess now than thirty or forty years ago ; that there 
is vast mischief done by ignorant pretenders to know- 
ledge in regard to the disease, and in view of the pro- 
bability that a majority of southern physicians will 
be called upon to treat the disease, we trust that this 
able and comprehensive treatise will be very gene- 
rally read in the south. — Memphis Med. Recorder. 



From Professor S. H. Dickson, Charleston, S. C, 
September 18, 1855. 

A monument of intelligent and well applied re- 
search, almost without, example. It is, indeed, in 
itself, a large library, and is destined to constitute 
the special resort as a book of reference, in the 
subject of which it treats, to all future time. 

"VVe have not time at present, engaged as we are, 
by da t y and by night, in the work of combating this 
very disease, now prevailing in our city, to do more 
than give this cursory notice of what we consider 
as undoubtedly the most able and erudite medical 
publication our country has yet produced. But in 
view of the startling fact, tha't this, the most malig- 



BY THE SAME AUTHOR. 

its Supposed Connection, Pathological and Etiological, with An- 



PNEUMONIA; 

tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one 
handsome octavo volume, extra cloth, of 500 pages. $3 00. 



LUDLOW (J. L.), M. D. 

A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, 
Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To 
which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended 
and enlarged. "With 370 illustrations. In one handsome royal 12mo. volume, leather, of 816 
large pages, $2 50. 

The great popularity of this volume, and the numerous demands for it during the two years m which 
it has been out of print, have induced the author in its revision to spare no pains to render it a 
correct and accurate digest of the most recent condition of all the branches of medical science. In 
many respects it may, therefore, be regarded rather as a new book than a new edition, an entire 
section on Physiology having been added, as also one on Organic Chemistry, and many portions 
having been rewritten. A very complete series of illustrations has been introduced, and every 
care has been taken in the mechanical execution to render it a convenient and satisfactory book for 
study or reference. The arrangement of the volume in the form of question and answer renders it 
especially suited for the office examination of students and for those preparing for graduation. 

We know of no better companion for the student I crammed into his head by the various professors to 
during the hours spent in the lecture room, or to re- whom he is compelled to listen. — Western Lancet, 
fresh, at a glance, his memory of the various topics | May, 1857. 

LEHMANN (C. G.) 
PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by 
George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry 
in the Medical Department of the University of Pennsylvania, with illustrations selected from 
Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large 
and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- 
trations. $6 00. 

The work of Lehmann stands unrivalled as the 
most comprehensive book of reference and informa- 
tion extant on every branch of the subject on which 
it treats. — Edinburgh Journal of Medical Science. 

by the same author. (Lately 'Published.') 

MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, 

with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital 
Force, by Professor Samuel Jackson, M. D., of the University of Pennsylvania. With illus- 
trations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. 

Frowi Prof. Jackson's Introductory Essay. 
In adopting the handbook of Dr. Lehmann as a manual of Organic Chemistry for the use of the 
students of the University, and in recommending his original work of Physiological Chemistry 
for their more mature studies, the high value of his researches, and the great weight of his autho- 
rity in that important department of medical science are fully recognized. 



The most important contribution as yet made to 
Physiological Chemistry Am. Journal Med. Sci- 
ences, Jan. 1856. 



AND SCIENTIFIC PUBLICATIONS. 



21 



LAWRENCE (W.), F. R. S., &c. 
A TREATISE ON DISEASES OF THE EYE. A new edition, edited, 

with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- 
tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather 
with raised bands. $5 00. 

MEIGS (CHARLES D.), M. D., 

Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. 

OBSTETRICS : THE SCIENCE AND THE ART. Third edition, revised 

and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo 

volume, leather, of seven hundred and fifty-two large pages. $3 75. 

The rapid demand for another edition of this work is a sufficient expression of the favorable 
verdict of the profession. In thus preparing it a third time for the press, the author has endeavored 
to render it in every respect worthy of the favor which it has received. To accomplish this he 
has thoroughly revised it in every part. Some portions have been rewritten, others added, new 
illustrations have been in many instances substituted for such as were not deemed satisfactory, 
while, by an alteration in the typographical arrangement, the size of the work has not been increased, 
and the price remains unaltered. In its present improved form, it is, therefore, hoped that the work 
will continue to meet the wants of the American proiession as a sound, practical, and extended 
System of Midwifery. 



The best American work on Midwifery that is 
accessible to the student and practitioner — N. W. 
Med. and Surg. Journal, Jan. 1857. 

This is a standard work by a great American Ob- 
stetrician. It is the third and last edition, and, in 
the language of the preface, the author has "brought 
the subject up to the latest dates of real improve- 
ment in our art and Science." — Nashville Journ. of 
Med. and Surg., May, 1857. 
BY THE SAME AUTHOR. (Just Issued .) 

WOMAN : HER DISEASES AND THEIR REMEDIES. A Series of Leo* 

tures to his Class. Fourth and Improved edition. In one large and beautifully printed octavo 
volume, leather, of over 700 pages. $3 60. 



Though the work has received only five pages of 
enlargement, its chapters throughout wear the im- 
press of careful revision. Expunging and rewriting, 
remodelling its sentences, with occasional new ma- 
terial, all evince a lively desire that it shall deserve 
to be regarded as improved in manner as well as 
matter. In the matter, every stroke of the pen has 
increased the value of the book, both in expungings 
and additions — Western Lancet, Jan. 1857. 



In other respects, in our estimation, too much can- 
not be said in praise of this work. Ic abounds with 
beautiful passages, and for conciseness, for origin- 
ality, and for all that is commendable in a work on 
the diseases of females, it is not excelled, and pro- 
bably not equalled in the English language. On the 
whole, we know of no work on the diseases of wo- 
men which we can so cordially commend to the 
student and practitioner as the one before us. — Ohio 
Med. and Surg. Journal. 

The body of the book is worthy of attentive con- 
sideration, and is evidently the production of a 
clever, thoughtful, and sagacious physician. Dr. 
Meigs's letters on the diseases of the external or- 
gans, contain many interesting and rare cases, and 
many instructive observations. We take our leave 
of Dr. Meigs, with a high opinion of his talents and 
originality.— The British and Foreign Medico-Chi- 
rurgical Review. 

Every chapter is replete with practical instruc- 
tion, and bears the impress of being the composition 
of an acute and experienced mind. There is a terse- 
ness, and at the same time an accuracy in his de- 
scription of symptoms, and in the rules for diagnosis, 
which cannot fail to recommend the volume to the 
attention of the reader. — Banking's Abstract. 

It contains a vast amount of practical knowledge, 
by one who has accurately observed and retained 
the experience of many years. — Dublin Quarterly 
Journal. 



Full of important matter, conveyed in a ready and 
agreeable manner.— St. Louis Med. and Surg. Jour. 

There is an off-hand fervor, a glow, and a warm- 
heartedness infecting the eff irt of Dr. Meigs, which 
is entirely captivating, and which absolutely hur- 
ries the reader through from beginning to end. Be- 
sides, the book teems with solid instruction, and 
it shows the very highest evidence of ability, viz., 
the clearness with which the information is pre- 
sented. We know of no better test of one's under- 
standing a subject than the evidence of the power 
of lucidly explaining it. The most elementary, as 
well as the obscurest subjects, under the pencil of 
Prof. Meigs, are isolated and made to stand out in 
such bold relief, as to produce distinct impressions 
upon the mind and memory of the reader. — Tht 
Charleston Bled. Journal. 

Professor Meigs has enlarged and amended this 
great work, for such it unquestionably is, having 
passed the ordeal of criticism at home and abroad, 
but been improved thereby ; for in this new edition 
the author has introduced real improvements, and 
increased the value and utility of the book im- 
measurably. It presents so many novel, bright, 
and sparkling thoughts; such an exuberance of new 
ideas on almost every page, that we confess our- 
selves to have become enamored with the book 
and its author ; and cannot withhold our congratu- 
lations from our Philadelphia confreres, that such a 
teacher is in their service. — N. Y. Med. Gazette. 



BY THE SAME AUTHOR. 

ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED 

FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome 
octavo volume, extra cloth, of 365 pages. $2 50. 



The instructive and interesting author of this 
work, whose previous labors have placed his coun- 
trymen under deep and abiding obligations, again 
challenges their admiration in the fresh and vigor- 
ous, attractive and racy pages before us. It is a de- 

BY THE SAME AUTHOR I 



lectable book. * * * This treatise upon child- 
bed fevers will have an extensive sale, being des- 
tined, as it deserves, to find a place in the library 
of every practitioner who scorns tolag in the rear. — 
Nashville, Journal of Medicine and Surgery. 
WITH COLORED PLATES. 



A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK 

OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest 
style of art. In one handsome octavo volume, extra cloth. $4 50. 



MAYNE'S DISPENSATORY AND THERA- 
PEUTICAL REMEMBRANCER. With every 
Practical Formula contained in the three British 
Pharmacopoeias. Edited, with the addition of the 
Fermuloe of the U. S. Pharmacopoeia, by R. E. 
Griffith, M.D. 1 12mo. vol. ex. cl. ,200pp. 75 c. 



MALGAIGNE'S OPERATIVE SURGERY, based 
on Normal and Pathological Anatomy. Trans- 
lated from the French by F redbrick Buittan, 
A.B.,M.D. With numerous illustrations on wood. 
In one handsome octavo volume, extra a] 
nearly six hundred pages. $9 'Jo. 



22 



BLANCHARD & LEA'S MEDICAL 



MACLISE (JOSEPH), SURGEON. 

SURGICAL ANATOMY. Forming one volume, very large imperial quarto. 
With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- 
taining one hundred and ninety Figures, many of them the size of life. Together with copious 
and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the 
cheapest and best executed Surgical works as yet issued in this country. $11 00. 
%* The size of this work prevents its transmission through the post-office as a whole, but those 

who desire to have copies forwarded by mail, can receive them in five parts, done up in stout 

wrappers. Price $9 00. 



One of the greatest artistic triumphs of the age 
in Surgical Anatomy. — British American Medical 
Journal . 

No practitioner whose means will admit should 
fail to possess it. — Banking's Abstract. 

Too much cannot be said in its praise; indeed, 
we have not language to do it justice. — Ohio Medi- 
cal and Surgical Journal. 

The most accurately engraved and beautifully 
colored plates we have ever seen in an American 
book — one of the best and cheapest surgical works 
ever published. — Buffalo Medical Journal. 

It is very rare that so elegantly printed, so well 
illustrated, and so useful a work, is offered at so 
moderate a price. — Charleston Medical Journal. 

Its plates can boast a superiority which places 
them almost beyond the reach of competition. — Medi- 
cal Examiner. 

Country practitioners will find these plates of im- 
mense value.— N. Y. Medical Gazette. 



A work which has no parallel in point of accu- 
racy and cheapness in the English language. — N. Y. 
Journal of Medicine. 

We are extremely gratified to announce to the 
profession the completion of this truly magnificent 
work, which, as a whole, certainly stands unri- 
valled, both for accuracy of drawing, beauty of 
coloring, and all the requisite explanations of the 
subject in hand. — The New Orleans Medical and 
Surgical Journal. 

This is by far the ablest work on Surgical Ana- 
tomy that has come under our observation. We 
know of no other work that would justify a stu- 
dent, in any degree, for neglect of actual dissec- 
tion. In those sudden emergencies that so often 
arise, and which require the instantaneous command 
of minute anatomical knowledge, a work of this kind 
keeps the details of the dissecting-room perpetually 
fresh in the memory. — The Western Journal of Medi- 
cine and Surgery. 



MILLER (HENRY), M . D., 

Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. 

PRINCIPLES AND PRACTICE OF OBSTETRICS, &c. ; including the Treat- 
ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent 
cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- 
tavo volume, of over 600 pages. {Lately Published.) $3 75. 

The reputation of Dr. Miller as an obstetrician is too widely spread to require the attention of 
the profession to be specially called to a volume containing the experience of his long and extensive 
practice. The very favorable reception accorded to his " Treatise on Human Parturition," issued 
some years since, is an earnest that the present work will fulfil the author's intention of providing 
within a moderate compass a complete and trustworthy text-book for the student, and book of re- 
ference for the practitioner. 

tion to which its merits justly entitle it. The style 
is such that the descriptions are clear, and each sub- 
ject is discussed and elucidated with due regard to 
its practical bearings, which cannot fail to make it 
acceptable and valuable to both students and prac- 
titioners. We cannot, however, close this brief 
notice without congratulating the author and the 
profession on the production of such an excellent 
treatise. The author is a western man of whom we 
feel proud, and we cannot but think that his book 
will find many readers and warm admirers wherever 
obstetrics is taught and studied as a science and an 
art. — The Cincinnati Lancet and Observer, Feb. 1858. 
A most respectable and valuable addition to our 
home medical literature, and one reflecting credit 
alike on the author and the institution to which he 
is attached. The student will find in this work a 
most useful guide to his studies; the country prac- 
titioner, rusty in his reading, can obtain from its 
pages a fair resume of the modern literature of the 
science; and we hope to see this American produc- 
tion generally consulted by the profession. — Va, 
Med. Journal, Feb. 1858. 



We congratulate the author that the task is done. 
We congratulate him that he has given to the medi- 
cal public a work which will secure for him a high 
and permanent position among the standard autho- 
rities on the principles and practice of obstetrics. 
Congratulations are not less due to the medical pro- 
fession of this country, on the acquisition of a trea- 
tise embodying the results of the studies, reflections, 
and experience of Prof. Miller. Few men, if any, 
in this country, are more competent than he to write 
on this department of medicine. Engaged for thirty- 
five years in an extended practice of obstetrics, for 
many years a teacher of this branch of instruction 
in one of the largest of our institutions, a diligent 
student as well as a careful observer, an original and 
independent thinker, wedded to no hobbies, ever 
ready to consider without prejudice new views, and 
to adopt innovations if they are really improvements, 
and withal a clear, agreeable writer, a practical 
treatise from his pen could not fail to possess great 
value. — Buffalo Med Journal, Mar. 1858. 

In fact, this volume must take its place among the 
standard systematic treatises on obstetrics ; a posi- 



MACKENZIE (W.), M. D., 

Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. &c. 

A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE 

EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of 
the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- 
larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to 
Wills Hospital, &c. &c. In one very large and handsome octavo volume, leather, raised bands, with 
plates and numerous wood-cuts. $5 25. 



The treatise of Dr. Mackenzie indisputably holds 
the first place, and forms, in respect of learning and 
research, an Encyclopaedia unequalled in extent by 
any other work of the kind, either English or foreign. 
— Dixon on Diseases of the Eye. 

Few modern books on any department of medicine 
or surgery have met with such extended circulation, 
or have procured for their authors a like amount of 
European celebrity. The immense research which 
it displayed, the thorough acquaintance with the 
subject, practically as well as tl Really, and the 



able manner in which the author's stores of learning 
and experience were rendered available for general 
use, at once procured for the first edition, as well on 
the continent as in this country, that high position 
as a standard work which each successive edition 
has more firmly established. We consider it the 
duty of every one who has the love of his profession 
and the welfare of his patient at heart, to make him- 
self familiar with this the most complete work in 
the English language upon the diseases of the eye. 
— Med. Times and Gazette. 



AND SCIENTIFIC PUBLICATIONS. 



MILLER (JAMES), F. R. S. E., 

Professor of Surgery in the University of Edinburgh, &c. 

PRINCIPLES OF SURGERY. Fourth American, from the third and revised 
Edinburgh edition. In one large and very beautiful volume, leather, of 700 pages, with two 
hundred and forty illustrations on wood. $3 75. 



The work takes rank with Watson's Practice of 
Physic; it certainly does not fall behind that great 
work in soundness of principle or depth of reason- 
ing and research. No physician who values his re- 
putation, or seeks the interests of his clients, can 
acquit himself before his God and the world without 
making himself familiar with the sound and philo- 
sophical views developed in the foregoing book. — 
New Orleans Med. and Surg. Journal. 

BY THE SAME AUTHOR. (Just Issued.) 

THE PRACTICE OF SURGERY. Fourth American from the last Edin- 

burgh edition. Revised by fhe American editor. Illustrated by three hundred and sixty- four 
engravings on wood. In one large octavo volume, leather, of nearly 700 pages. $3 75. 



The work of Mr. Miller is too well and too favor- 
ably known among us, as one of our best text-books, 
to render any further notice of it necessary than the 
announcement of a new edition, the fourth in our 
country, a proof of its extensive circulation among 
us. As a concise and reliable exposition of the sci- 
ence of modern surgery, it stands deservedly high — 
we know not its superior. — Boston Med. and Surg. 
Journal. 



No encomium of ours could add to the popularity 
of Miller's Surgery. Its reputation in this country 
is unsurpassed by that of any other work, and, when 
taken in connection with the author's Principles of 
Surgery, constitutes a whole, without reference to 
to which no conscientious surgeon would be willing 
practice his art. — Southern Med . and Surg . Journal. 

It is seldom that two volumes have ever made so 
profound an impression in so short a time as the 
"Principles" and the "Practice" of Surgery by 
Mr. Miller — or so richly merited the reputation they 
have acquired. The author is an eminently sensi- 
ble, practical, and well-informed man, who knows 
exactly what he is talking about and exactly how to 
talk it. — Kentucky Medical Recorder. 

By the almost unanimous voice of the profession, 



his works, both on the principles and practice of I 
surgery have been assigned the highest rank. If we 
were limited to but one work on surgery, that one 
should be Miller's, as we regard it as superior to all 
others. — St. Louis' Med. and Surg. Journal. 

The author has in this and his " Principles," pre- 
sented to the profession one of the most complete and 
reliable systems of Surgery extant. His style of 
writing is original, impressive, and engaging, ener- 
getic, concise, and lucid. Few have the faculty of 
condensing so much in small space, and at the same 
time so persistently holding the attention. Whether 
as a text-book for students or a book of reference 
for practitioners, it cannot be too strongly recom- 
mended. — Southern Journal of Med. and Physical 
Sciences. 



MORLAND (W. W.), M. D., 

Fellow of the Massachusetts Medical Society, &c. 

DISEASES OF THE URINARY ORGANS j a Compendium of their Diagnosis, 



Pathology, and Treatment. With illustrations 
about 600 pages, extra cloth. (Just Issued.) 

Taken as a whole, we can recommend Dr. Mor- 
land's compendium as a very desirable addition to 
the library of every medical or surgical practi- 
tioner.— Brit, and For. Med.-Chir. Rev., April, 1859. 

Every medical practitioner whose attention has 
been to any extent attracted towards the class of 
diseases to which this treatise relates, must have 
often and sorely experienced the want of some full, 
yet concise recent compendium to which he could 
refer. This desideratum has been supplied by Dr. 
Morland, and it has been ably done. He has placed 
before us a full, judicious, and reliable digest. 
Each subject is treated with sufficient minuteness, 



In one large and handsome octavo volume, oi 

yd 50. 

yet in a succinct, narrational style, such as to render 
the work one of great interest, and one which will 
prove in the highest degree useful to the general 
practitioner. To the members of the profession in the 
country it will be peculiarly valuable, on account 
of the characteristics which we have mentioned, 
and the one broad aim of practical utility which is 
kept in view, and which shines out upon every page, 
together with the skill which is evinced in the com- 
bination of this grand requisite with the utmost 
brevity which a just treatment of the subjects would 
admit. — N. Y. Journ. of Medicine, Nov. 1858. 



MONTGOMERY (W. F.), M. D., M. R. I. A., &c, 

Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c. 

AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. 

With some other Papers on Subjects connected with Midwifery. From the second and enlarged 
English edition. With two exquisite colored plates, and numerous wood-cuts. In one very 
handsome octavo volume, extra cloth, of nearly 600 pages. (Lately Published.) $3 75. 



A book unusually rich in practical suggestions. — 
Am. Journal Med. Sciences, Jan. 1857. 

These several subjects so interesting in them- 
selves, and so important, every one of them, to the 
most delicate and precious of social relations, con- 
trolling often the honor and domestic peace of a 
family, the legitimacy of offspring, or the life of its 
parent, are all treated with an elegance of diction, 
fulness of illustrations, acutenessand justice of rea- 
soning, unparalleled in obstetrics, and unsurpassed in 
medicine. The reader's interest can never flag, so 
fresh, and vigorous, and classical is our author's 
style; and one forgets, in the renewed charm of 
every page, that it, and every line, and every word 



has been weighed and reweighed through years of 
preparation; that this is of all others the book of 
Obstetric Law, on each of its several topics ; on all 
points connected with pregnancy, to be everywhere 
received as a manual of "special jurisprudence, at 
once announcing fact, affording argument, establish- 
ing precedent, and governing alike the juryman, ad- 
vocate, and judge. It is not merely in its legal re- 
lations that we find this work so interesting. Hardly 
a page but that has its hints or facts important to 
the general practitioner; and not a chapter without 
especial matter for the anatomist, physiologist, or 
pathologist. — N. A. Med.-Chir. Review. March, 
1857. 



MOHR (FRANCIS), PH. D., AND REDWOOD (THEOPHILUS). 

PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and 
Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, 
by Prof. William Procter, of the Philadelphia College oi' Pharmacy. In one handsomely 
printed octavo volume, extra cloth, oi 570 pages, with over 000 engravings on wood. $2 75 



24 



BLANCHARD & LEA'S MEDICAL 



IMESLL (JOHN), M. D., 

Surgeon to the Pennsylvania Hospital, &c .; and 

FRANCIS GURNEY SMITH, M. D., 

Professor of Institutes of Medicine in the Pennsylvania Medical College. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES 

OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised 
and improved. In one very large and handsomely printed royal 12mo. volume, of about one 
thousand pages, with 374 wood-cuts. Strongly bound in leather, with raised bands, §3 00. 
The very nattering reception which has been accorded to this work, and the high estimate placed 
upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- 
hausted two large editions, have stimulated the authors to render the volume in its present revision 
more worthy of the success which has attended it. It has accordingly been thoroughly examined, 
and such errors as had on former occasions escaped observation have been corrected, and whatever 
additions were necessary to maintain it on a level with the advance of science have been introduced. 
The extended series of illustrations has been still further increased and much improved, while, by 
a slight enlargement of the page, these various additions have been, incorporated without increasing 
the bulk of the volume. 

The work is, therefore, again presented as eminently worthy of the favor with which it has hitherto 
been received. As a book for daily reference by the student requiring a guide to his more elaborate 
text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate 
examination, or as a source from which the practitioners of older date may easily and cheaply acquire 
a knowledge of the changes and improvement in professional science, its reputation is permanently 
established. 

the students is heavy, and review necessary for an 
examination, a compend is not only valuable, but 
it is almost a sine qua non. The one before us is, 
in most of the divisions, the most unexceptionable 
of all books of the kind that we know of. The 
newest and soundest doctrines and the latest im- 
provements and discoveries are explicitly, though 
concisely, laid before the student. There is a class 
to whom we very sincerely commend thi3 cheap book 
as worth its weight in silver — that class is the gradu- 
ates in medicine of more than ten years' standing, 
who have not studied medicine since. They will 
perhaps find out from it that the science is not exactly 
now what it was when they left it off. — The Stetho- 
scope. 



The best work of the kind with which we are 
acquainted. — Med. "Examiner. 

Having made free use of this volume in our ex- 
aminations of pupils, we can speak from experi- 
ence in recommending it as an admirable compend 
for students, and as especially useful to preceptors 
who examine their pupils. It will save the teacher 
much labor by enabling him readily to recall all of 
the points upon which his pupils should be ex- 
amined. A work of this sort should be in the hands 
of every one who takes pupils into his office with a 
view of examining them ; and this is unquestionably 
thebestof its class. — Transylvania Med. Journal, 

In the rapid course of lectures, where work for 



(A splendid work. Just Issued.) 

ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra 

cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of 
disease. $4 50. 

This beautiful volume is intended as a complete and accurate representation of all the varieties 
of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has 
especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the 
profession some years since. The publishers feel justified in saying that few more beautifully exe- 
cuted plates have ever been presented to the profession of this country. 

give, at a coup d'aeil, the remarkable peculiarities 
of each individual variety. And while thus the dis- 
ease is rendered more definable, there is yet no loss 
of proportion incurred by the necessary concentra- 
tion. Each figure is highly colored, and so truthful 
has the artist been that the most fastid ; ous observer 
could not justly take exception to the correctness of 
the execution of the pictures under his scrutiny. — 
Montreal Med. Chronicle. 



Neligan's Atlas of Cutaneous Diseases supplies a 
long existent desideratum much felt by the largest 
class of our profession. It presents, in quarto size, 
16 plates, each containing from 3 to 6 figures, and 
forming in all a total of 90 distinct representations 
of the different species of skin affections, grouped 
together in genera or families. The illustrations 
have been taken from nature, and have been copied 
with such fidelity that they present a striking picture 
of life; in which the reduced scale aptly serves to 



BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON DISEASES OE THE SKIN. 

American edition. In one neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. 
The two volumes will be sent by mail on receipt of Five Dollars. 



Third 



OWEN ON THE DIFFERENT FORMS OF 
THE SKELETON, AND OF THE TEETH, 



One vol. royal 12mo., extra cloth with numerous 
illustrations. $1 25. 



P I RRIE (WILLIAM), F. R. S. E., 

Professor of Surgery in the University of Aberdeen. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John 

Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania 

Hospital, &c. In one very handsome octavo volume, leather, of 780 pages, with 316 illustrations. 

$3 75. 

We know of no other surgical work of a reason- 
able size, wherein there is so much theory and prac- 
tice, or where subjects are more soundly or clearly 
taught. — The Stethoscope. 

Prof. Pirrie, in the work before us, has elabo- 



rately discussed the principles of surgery, and a 
safe and effectual practice predicated upon them. 
Perhaps no work upon this subject heretofore issued 
is so full upon the science of the art of surgery. — 
Nashville Journal of Medicine and Surgery. 



AND SCIENTIFIC PUBLICATIONS. 



25 



PARRISH (EDWARD), 

Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, &c. 

AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- 
Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many For- 
mulae and Prescriptions. Second edition, greatly enlarged and improved. In one handsome 
octavo volume of 720 pages, with several hundred Illustrations, extra cloth. $3 00. (Now 
Ready.) 

During the short time in which this work has been before the profession, it has been received 
with very great favor, and in assuming the position of a standard authority, it has filled a vacancy 
which had been severely felt. Stimulated by this encouragement, the author, in availing himself 
of the opportunity of revision, has spared no pains to render it more worthy of the confidence be- 
stowed upon it, and his assiduous labors have made it rather a new book than a new edition, many 
portions having been rewritten, and much new and important matter added. These alterations and 
improvements have been rendered necessary by the rapid progress made by pharmaceutical science 
during the last few years, and by the additional experience obtained in the practical use of the 
volume as a text-book and work of reference. To accommodate these improvements, the size of 
the page has been materially enlarged, and the number of pages considerably increased, presenting 
in all nearly one -half more matter than the last edition. The work is therefore now presented as a 
complete exponent of the subject in its most advanced condition. From the most ordinary matters 
in the dispensing office, to the most complicated details of the vegetable alkaloids, it is hoped that 
everything requisite to the practising physician, and to the apothecary, will be found fully and 
clearly set forth, and that the new matler alone will be worth more than the very moderate cost of 
the work to those who have been consulting the previous edition. 



That Edward Parrish, in writing a book upon 
practical Pharmacy some few years ago — one emi- 
nently original and unique — did the medical and 
pharmaceutical professions a great and valuable ser- 
vice, no one, we think, who has had access to its 
pages will deny ; doubly welcome, then, is this new 
edition, containing the added results of his recent 
and rich experience as an observer, teacher, and 
practicd operator in the pharmaceutical laboratory. 
The excellent plan of the first is more thoroughly, 
and in detail, carried out in this edition.— Peninsular 
Med. Journal, Jan. I860. 

We know of no work on the subject which would 
be more indispensable to the physician or student 
desiring information on the subject of which it treats. 
With Griffith's " Medical Formulary" and this, the 
practising physician would be supplied with nearly 
or quite all the most useful information on the sub- 
ject. — Charleston Med. Journal and Review, Jan. 
1860. 

This edition, now much enlarged, is one of the 
most useful works of the past year. — N. O. Med. 
and Surg. Journal, Jan. 1860. 

The whole treatise is eminently practical; and 



there is no production of the kind in the English 
language so well adapted to the wants of the phar- 
maceutist and druggist. To physicians, also, it can- 
not fail to be highly valuable, especially to those 
who are obliged to prepare and compound many of 
their own medicines. — N. Am. Med. Chir. Review, 
Jan. 1860. 

Of course, all apothecaries who have not already 
a copy of the first edition will procure one of this; 
it is, therefore, to physicians residing in the country 
and in small towns, who cannot avail themselves of 
the skill of an educated pharmaceutist, that we 
would especially commend this work. In it they 
will find all that they desire to know, and should 
know, but very little of which they do really snow 
in reference to this important collateral branch of 
their profession; for it is a well established fact, 
that, in the education of physicians, while the sci- 
ence of medicine is geneially well taught, very 
little attention is paid to the art of preparing them 
for use, and we know not how this defect can be so 
well remedied as by procuring and consulting Dr. 
PaTrish's excellent work.— St. Louis Med. Journal. 
Jan. 1860. 



PEASLEE (E. R.) 3 M. D., 
Professor of Physiology and General Pathology in the New York Medical College. 

HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; 
for the use of Medical Students. With four hundred and thirty-four illustrations. In one hand- 
some octavo volume, of over 600 pages. (Lately Published.) $3 75. 
It embraces a library upon the topics discussed 
within itself, and is just, what the teacher and learner 
need. Another advantage, by no means to be over- 
looked, everything of real value in the wide range 
which it embraces, is with great skill compressed 
into an octavo volume of but little more than six 
hundred pages. We have not only the whole sub- 
ject of Histology, interesting in itself, ably and fully 
discussed, but what is of infinitely greater interest 
to the student, because of greater practical value, 
are its relations to Anatomy, Physiology, and Pa- 
thology, which are here fully and satisfactorily set 
forth.— Nashville J ourn. of Med. and Surgery, Dec. 
1857. 



We would recommend it to the medical student 
and practitioner, as containing a summary of all that 
is known of the important subjects which it treats ; 
of all that is contained in the great works of Simon 
and Lehmann, and the organic chemists in general. 
Master this one volume, we would say to the medical 
student and practitioner — master this book and you 
know all that is known of the great fundamental 
principles of medicine, and we have eo hesitation 
in saying that it is aa honor to the American medi- 
cal profession that one of its members should have 
produced it. — St. Louis Mid. and Surg. Journal, 
March, 1S58. 



PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. 
THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. 

Third American edition, enlarged and improved by the author; including Notices o roost of the 
Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia 
Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and 
Pharmacy in the University of Pennsylvania. In two very large octavo volumes pi 2 LOO paces. 
on small type, with about 500 illustrations on stone and wood, strongly bound i leather, with 
raised bands. $y 00. 
%** Vol. II. will no longer be sold separate. 

PARKER (LANGSTON), 

Surgeon to the Queen's Hospital, Birmingham, 

THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- 
MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- 
lis, by a safe and successful method. With numerous Cases, Formulae, and Clinical Observa- 
tions. From the Third and entirely rewritten London edition. In one neat octavo volume. 
extra cloth, of 316 pages. $1 75. 



26 



BLANCHARD & LEA'S MEDICAL 



FIAMSBOTHAM (FRANCIS H .), M.D. 
THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND 

SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly 
revised by the Author. With Additions by W. V. Keating, M. D. In one large and handsome 
imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty- 
four beautiful Plates, and numerous Wood-cuts in the text s containing in all nearly two hundred 
large and beautiful figures. $5 00. 

From Prof. Hodge, of the University of Pa. 
To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being 

the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout 

our country. 



It is unnecessary to say anything in regard to the 
utility of this work. It is already appreciated in our 
country for the value of the matter, the clearness of 
its style, and the fulness of its illustrations. To the 
physician's library it is indispensable, while to the 
student as a text-book, from which to extract the 
material for laying the foundation of an education on 
obstetrical science, it has no superior. — Ohio Med. 
and Surg. Journal. 

The publishers have secured its success by the 



truly elegant style in which they have brought it 
out, excelling themselves in its production, espe- 
cially in its plates. It is dedicated to Prof. Meigs, 
and has the emphatic endorsement of Prof. Hodge, 
as the best exponent of British Midwifery. We 
knew of no text-book which deserves in all respects 
to be more highly recommended to students, and we 
could wish to see it in the hands of every practitioner, 
for they will find it invaluable for reference. — Med. 
Gazette. 



RICORD (P.), M. D. 
A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R, S. 

With copious Additions, by Ph. Ricord, M.D. Translated and Edited, with Notes, by Freeman 
J. Bumsteab. M.D., Lecturer on Venereal at the College of Physicians and Surgeons, New York. 
Second edition, revised, containing ^resume of Ricord's Recent Lectures on Chancre. In 
one handsome octavo volume, extra cloth, of 550 pages, with eight plates. $3 25. ( Just Issued.) 
In revising this work, the editor has endeavored to introduce whatever matter of interest the re- 
cent investigations of syphilographers have added to our knowledge of the subject. The principal 
source from which this has been derived is the volume of "Lectures on Chancre," published a few 
months since by M. Ricord, which affords a large amount of new and instructive material on many 
controverted points. In the previous edition, M. Ricord's additions amounted to nearly one-third 
of the whole, and with the matter now introduced, the work may be considered to present his views 
and experience more thoroughly and completely than any other. 



Every one will recognize the attractiveness and 
value which this work derives from thus presenting 
the opinions of these two masters side by side. But, 
it must be admitted, whai has made the fortune of 
the book, is the fact that it contains the "most com- 
plete embodiment of the veritable doctrines of the 
Hopital du Midi," which has ever been made public. 
The doctrinal ideas of M. Ricord. ideas which, if not 
universally adopted, are incontestably dominant, have 
heretoforeoniybeeninterpretedbymoreorlessskilful 



secretaries, sometimes accredited and sometimes not. 
In the notes to Hunter, the master substitutes him- 
self forhis interpreters, and gives hisoriginal thoughts 
to the world in a lucid and perfectly intelligible man- 
ner. In conclusion we can say that this is incon- 
testably the best treatise on syphilis with which we 
are acquainted, and, as we do not often employ the 
phrase, we may be excused for expressing the hope 
place in the library of every phy- 



Med. and Surg. Journal. 



that it may find 
sician. — Virgin 
BY THE SAME AUTHOR. 

RICORD'S LETTERS ON SYPHILIS. Translated by W. P. Lattimore ; M. D. 

In one neat octavo volume, of 270 pages, extra cloth. $2 00. 



(CARL), M. D., 

and Professor at the University of Vienna, &c. 



volumes, octavo 3 



ROYLE'S MATERIA MEDICA AND THERAPEUTICS; including the 

Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. 
With many new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations. 
In one large octavo volume, extra cloth, of about 700 pages. $3 00. 

ROKITANSKY 

Curator of the Imperial Pathological Museum, 

A MANUAL OF PATHOLOGICAL 

bound in two, extra cloth, of about 1200 pages. 

king, C. H. Moore, and G. E. Day. $5 50 

The profession is too well acquainted with the re- 
putation of Rokitansky's work to need our assur- 
ance that this is one of the mostprofound, thorough, 
and valuable books ever issued from the medical 
press. It is sui generis, and has no standard of com- 
parison. It is only necessary to announce that it is 
issued in a form as cheap as is compatible with its 
size and preservation, and its sale follows as a 
matter of course. No library can be called com- 
plete without it. — Buffalo Bled. Journal. 



ANATOMY. Four 

Translated by W. E. Swaine, Edward Sieve 



An attempt to give our readers any adequate idea 
of the vast amount of instruction accumulated in 
these volumes, would be feeble and hopeless. The 
effort of the distinguished author to concentrate 
in a small space his great fund of knowledge, has 



so charged his text with valuable truths, that any 
attempt of a reviewer to epitomize is at once para- 
lyzed, and must end in a failure. — Western Lancet. 

As this is the highest source of knowledge upon 
the important subject of which it treats, no real 
student can afford to be without it. The American 
publishers have entitled themselves to the thanks of 
the profession of their country, for this timeous and 
beautiful edition. — Nashville Journal of Medicine. 

As a book of reference, therefore, this work must 
prove of inestimable value, and we cannot too highly 
recommend it to the profession.— Charleston Med. 
Journal and Review. 

This book is a necessity to every practitioner.— 
Am. Med. Monthly. 



RIGBY (EDWARD), M.D., 

Senior Physician to the General Lying-in Hospital, &c. 

A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. 
Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. 
by the same author. [Lately Published.) 

ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. 

In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. 



AND SCIENTIFIC PUBLICATIONS 



27 



STILLE (ALFRED), M.D. 
THERAPEUTICS AND MATERIA MEDIC A; a Systematic Treatise on the 

Action, and Uses of Medicinal Agents, including their Description and History. In two large and 
handsome octavo volumes, of 1789 pages. {Now Ready, 1860.) $8 00. 

This work is designed especially for the student and practitioner of medicine, and treats the various 
articles of the Materia Medica from the point of view of the bedside, and not of the shop or of the 
lecture-room. While thus endeavoring to give all practical information likely to be useful with 
respect to the employment of special remedies in special affections, and the results to be anticipated 
from their administration, a copious Index of Diseases and their Remedies renders the work emi- 
nently fitted for reference by showing at a glance ihe different means which have been employed, 
and enabling the practitioner to extend his resources in difficult cases with all that the experience 
of the profession has suggested. At the same time particular care has been given to the subject 
of General Therapeutics, and at the commencement of each class of medicines there is a chapter 
devoted to the consideration of their common influence upon morbid conditions. The action of 
remedial agents upon the healthy economy and on animals has likewise received particular notice, 
from the conviction that their physiological effects will afford frequent explanations of their patho- 
logical influence, and in many cases lead to new and important suggestions as to their practical use 
in disease. Within the scope thus designed by the author, no labor has been spared to accumulate 
all the facts which have accrued from the experience of the profession in all ages and all countries ; 
and the vast amount of recent researches recorded in the periodical literature of both hemi>pheres 
has been zealously laid under contribution, resulting in a mass of practical information scarcely 
attempted hitherto in any similar work in the language. 



Our expectations of the value of this work were 
based on the well-known reputation and character 
of the author as a man of scholarly attainments, an 
elegant writer, a candid inquirer after truth, and a 
philosophical thinker ; we knew that the task would 
be conscientiously performed, and that few, if any, 
anions: the distinguished medical teachers in this 
country are better qualified than he to prepare a 
systematic treatise on therapeutics in accordance 
wilh the present requirements of medical science. 
Our preliminary examination of the work has satis- 
fied us that we were not mistaken in our anticipa- 
tions. In congratulating the author on the comple- 
tion of the great labor which such a work involves, 
we are happy in expressing the conviction that its 
merits will receive that reward which is above all 
price- the grateful appreciation of his medical bre- 
thren. — New Orleans Medical News, March, 1S60. 

We think this work will do much to obviate the 
reiuctance to a thorough investigation of this branch 
of scientific study, for in the wide range of medical 
literature treasured in the English tongue, we shall 
hardly find a work written in a style more clear and 
simple, conveying forcibly the facts taught, and yet 
free from turgidity and redundancy. There is a fas- 
cination in its pages that will insure to it a wide 
popularity and attentive perusal, and a degree of 
ussfulne&s not often attained through the influence 
of a single work. The author has much enhanced 



the practical utility of his book by passing briefly 
over the physical, botani 3al, and commercial history 
of medicines, and directing attention chiefly to their 
physiological action, and their application for the 
amelioration or cure of disease. He ignores hypothe- 
sis and theory which are so alluring to many medical 
writers, and so liable to lead them astray, and con- 
fines himself to such facts as have been tried in the 
crucible of experience. — Chicago Medical Journal, 
March, 1860. 

The plan pursued by the author in these very ela- 
borate volumes is not strictly one of scientific unity 
and precision; he has rather subordinated these to 
practical utility. Dr. Stille has produced a work 
which wilt be valuable equally to the student of 
medicine and the bus} practitioner.— London Lan- 
cet, March 10, 1860. 

With Pereira, Dunglison, Mitchell, and Wood be- 
fore us, we may well ask if there was a necessity 
for a new book on the subject. After examining this 
work with some care, we can answer affirmatively. 
Dr. Wood's book is well adapted for students, while 
Dr. Stille's will be more satisfactory to the practi- 
tioner, who desires to study the action of medicines . 
The author needs no encomiums from us, for he is 
well known as a ripe scholar and a man of the most 
extensive reading in his profession. This work bears 
evidence of this fact on every pige. — Cincinnati 
Lancet, April, lfcGO. 



SMITH (HENRY H.), M. D. 

MINOR SUKGERY; or, Hints on the Every-day Duties of the Surgeon. With 

247 illustrations. Third edition. 1 vol. royal 12mo., pp. 456. In leather, $2 25; cloth, $2 00. 

BY THE SAME AUTHOR, AND 

HORNER (WILLIAM E.), M.D., 
Late Professor of Anatomy in the University of Pennsylvania. 

AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. 
In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful 
figures. $3 00. 



These figures are well selected, and present a 
complete and accurate representation of that won- 
derful fabric, the human body. The plan of this 
Atlas, which renders it so peculiarly convenient 
for the student, and its superb artistical execution, 
have been already pointed out. We must congratu- 



late the student upon the completion of this Atlas, 
as it is the most convenient work of the kind tiiax 
has yet appeared ; and we must add. the very beau- 
tiful manner in which it is " got up" is so creditable 
to the country as to be nattering to our national 
pride. — American Medical Journal. 



SHARPEY (WILLIAM), M. D., JONES QUAIN, M. D., AND 

RICHARD QUAIN, F. R. S., &c. 

HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Letty, 

M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo 
volumes, leather, of about thirteen hundred pages. Beautifully illustrated with over live hundred 
engravings on wood. $6 00. 



SIMPSON (J. Y. , M. D., 

Professor of Midwifery, &c, in the Universitv of Edinburgh, &0. 

CLINICAL LECTURES ON THE DISEASES OF FEMALES. With mime- 

rous illustrations. 

This valuable series of practical Lectures is now appearing in the "Medical News anp 
Library" for 1S60, and can thus be had without cost by subscribers to the "American Journal 
of the Medical Sciences." See p. 2. 



BLANCHARD & LEA'S MEDICAL 



SARGENT (F. W.), M. D. 
ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. 

Second edition, enlarged. One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood- 
cuts. Extra cloth, $1 40 ; leather, $1 50. 



Sargent's Minor Surgery has always been popular, 
and deservedly so. It furnishes that knowledge of the 
most frequently requisite performances of surgical 
art which cannot be entirely understood by attend- 
ing clinical lectures. The art of bandaging, which 
is regularly taught in Europe, is very frequently 
overlooked by teachers in this country ; the student 
and junior practitioner, therefore, may often require 
that knowledge which this little volume so tersely 
and happily supplies. — Charleston Med. Journ. and 
Review. March, 1856. 



A work that has been so long and favorably known 
to the profession as Dr. Sargent's Minor Surgery, 
needs no commendation from us. We would remark, 
however, in this connection, that minor surgery sel- 
dom gets that attention in our schools that its im- 
portance deserves. Our larger works are also very 
defective in their teaching on these small practical 
points. This little book will supply the void which 
all must feel who have not studied its pages. — West- 
ern Lancet, March, 1856. 



SMITH (W. TYLER), M. D., 

Physician Accoucheur to St. Mary's Hospital, &c. 

ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF 

OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 25. 

BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT 

OF LEUCORRHCEA. With numerous illustrations. In one very handsome octavo volume, 
extra cloth, of about 250 pages. $1 50. 



SOLLY ON THE HUMAN BRAIN; its Structure, 
Physiology, and Diseases. From the Second and 
much enlarged London edition. In one octave 
volume, extra cloth, of 500 pages, with 120 wood- 
cuts. $2 00. 

SKEY'S OPERATIVE SURGERY. In one very 



handsome octavo volume, extra cloth, of over 650 
pages, with about one hundred wood-cuts. $>3 25. 
SIMON 1 !? GENERAL PATHOLOGY, as conduc- 
ive to the Establishment of Rational Principles 
for the prevention ano Cure of Disease. In one 
octavo volume, extra cloth, of 212 pages. $1 25. 



TODD (R. B.}, M.D., F. R B S., &c. 

CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY 

ORGANS AND ON DROPSIES. In one octavo volume, 284 pages. $1 50. 
by the same author. (Now Ready.) 

CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat 

octavo volume, of 320 pages, extra cloth. $1 75. 

The subjects treated in this volume are — Rheumatic Fever, Continued Fever, Erysipelas, 
Acute Internal Inflammation, Pyaemia, Pneumonia, and the Therapeutical Action of Alco- 
hol. The importance of these matters in the daily practice of every physician, and the sound 
practical nature of Dr. Todd's writings, can hardly fail to attract to this work the general attention 
that it merits. 



TANNER (T. H.), M. D., 

Physician to the Hospital for Women, &c. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. 

To which is added The Code of Ethics of the American Medical Association. Second 
American Edition. In one neat volume, small 12mo., extra cloth, 87a cents. 



TAYLOR (ALFRED S.) } M. D., F. R. $., 

Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. 

MEDICAL JURISPRUDENCE. Fourth American Edition. With Notes and 

Referencesto American Decisions, by Edward Hartshorne, M. D. In one large octavo volume, 
leather, of over seven hundred pages. $3 00. 



No work upon the subject can be put into the 
hands of students either of law or medicine which 
will engage them more closely or profitably ; and 
none could be offered to the busy practitioner of 
either calling, for the purpose of casual or hasty 
reference, that would be more likely to afford the aid 
desired. We therefore recommend it as the best and 
safest manual for daily use.— American Journal oj 
Medical Sciences. 



It is not excess of praise to say that the volume 
before us is the very best treatise extant on Medical 
Jurisprudence. In saying this, we do not wish to 
be understood as detracting from the merits of the 
excellent works of Beck, Ryan, Traill, Guy, and 
others ; but in interest and value we think it must 
be conceded that Taylor is superior to anything that 
has preceded it.— N. W. Medical and Surg. Journal. 



by the same author. (New Edition, just issued.) 

ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Second American, from a second and revised London edition. In one large 

octavo volume, of 755 pages, leather. $3 50. 

Since the first appearance of this work, the rapid advance of Chemistry has introduced into 
use many new substances which may become fatal through accident or design — while at the 
same time it has likewise designated new and more exact modes of counteracting or detecting those 
previously treated of. Mr. Taylor's position as the leading medical jurist of England, has during 
this period conferred on him extraordinary advantages in acquiring experience on these subjects, 
nearly all cases of moment being referred to him lor examination, as an expert whose testimony 
is generally accepted as final. The results of his labors, therefore, as gathered together in this 
volume, carefully weighed and sifted, and presented in the clear and intelligible style for which 
he is noted, may be received as an acknowledged authority, and as a guide to be folio wed with 
implicit confidence. 



AND SCIENTIFIC PUBLICATIONS. 29 

TODD (ROBERT BENTLEY), M. D., F. R. S,, 

Professor of Physiology in King's College, London; and 
WILLIAM BOWMAN, F. Ft. S., 

Demonstrator of Anatomy in King's College, London. 

THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With 

about three hundred large and beautiful illustrations on wood. Complete ia one large octavo 

volume, of 950 pages, leather. Price $4 50. 

Idp 3 Gentlemen who have received portions of this work, as published in the " Medical News 
and Library/' can now complete their copies, if immediate application be made. It will be fur- 
nished as follows, free by mail, in paper covers, with cloth backs. 

Parts I., II., III. (pp. 25 to 552), $2 50. 

Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), $2 00. 

Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25. 



A magnificent contribution to British medicine, 
ana the American physician who shall fail to peruse 
it, will have failed to read one of the most instruc- 
tive books of the nineteenth century. — iV. O. Med 
and Surg. Journal, Sept. 1857. 

It is more concise than Carpenter's Principles, and 
more modern than the accessible edition of Muller's 
Elements; its details are brief, but sufficient; its 
descriptions vivid ; its illustrations exact and copi- 
ous ; and its language terse and perspicuous. — 
Charleston Med. Journal, July, 1857. 

We know of no work on the subject of physiology 



so well adapted to the wants of the medical student. 
Its completion has been thus long delayed, that the 
authors might secure accuracy by personal observa- 
tion. — St. Louis Med. and Surg. Journal, Sept. '57. 

Our notice, though it conveys but a very feeble 
and imperfect idea of the magnitude and importance 
of the work now under consideration, already tran- 
scends our limits ; and, with the indulgtnce of our 
readers, and the hope that they will peruse the book 
for themselves, as we feel we can with confidence 
recommend it, we leave it in their hands. — The 
Northwestern Med. and Surg. Journal. 



TOYNBEE (JOSEPH), F. Ft. S., 

Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. 

A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diag- 

nosis, Pathology, and Treatment. Illustrated with one hundred engravings on wood. In one 
very handsome octavo volume, extra cloth, $3 00. (Now Ready.) 

Mr. Toynbee's name is too widely known as the highest authority on all matters connected with 
Aural Surgery and Medicine, to require special attention to be called to anything which he may 
communicate to the profession on the subject. Twenty years' labor devoted to the present work 
has embodied in it the results of an amount of experience and observation which perhaps no other 
living practitioner has enjoyed. It therefore cannot fail to prove a complete and trustworthy guide 
on all matters connected with this obscure and little known class of diseases, which so frequently 
embarrass the general practitioner. 

The volume will be found thoroughly illustrated with a large number of original wood-engrav- 
ings, elucidating the pathology of the organs of hearing, instruments, operations, &c, and in every 
respect it is one of the handsomest specimens of mechanical execution issued from the American 
press. 

The following condensed synopsis of the contents will show the plan adopted by the author, and 
the completeness with which all departments of the subject are brought under consideration. 
CHAPTER I. Introduction— Mode of Investigation— Dissection. II. The External Ear — Ana- 
tomy — Pathology — Malformations — Diseases, III. The External Meatus — Its Exploration. 
IV. The External Meatus — Foreign Bodies and Accumulations of Cerumen. V. The External 
Meatus— The Dermis and its Diseases. VI. The External Meatus— Polypi. VII. The External 
Meatus — Tumors. VIII. The Membrana Tympani — Structure and Functions. IX. The Mem- 
brana Tympani — Diseases. X. The Membrana Tympani — Diseases. XI. The Eustachian 
Tube — Obstructions. XII. The Cavity of the Tympanum — Anatomy — Pathology — Diseases. 
XIII. The Cavity of the Tympanum— Diseases. XIV. The Mastoid Cells— Diseases. XV. 
The Diseases of the Nervous Apparatus of the Ear, producing what is commonly called " Nerv- 
ous Deafness." XVI. The Diseases of the Nervous Apparatus, continued. XVII. Malignant 
Disease of the Ear. XVIII. On the Deaf and Dumb. XIX. Ear-Trumpets and their uses. 
Appendix. 



WILLIAMS (C. J. B.), M.D., F. R. S., 

Professor of Clinical Medicine in University College, London, &c. 

PRINCIPLES OP MEDICINE. Au Elementaiy View of the Causes, Nature, 

Treatment, Diagnosis, and Prognosis of Disease; with briei remarks on Hygienics, or the pre- 
servation of health. A new American, from the third and revised London edition. In one octavo 
volume, leather, of about 500 pages. $2 50. (Just Issued.) 

expressed. It is a judgment of almost unqualified 



We find that the deeply-interesting matter and 
style of this book have so far fascinated us, that we 
have unconsciously hung upon its pages, not too 
long, indeed, for our own profit, but longer than re- 
viewers can be permitted to indulge. We leave the 
further analysis to the student and practitioner. Our 
judgment of the work has already been sufficiently 



praise. — London Lancet. 

A text-book to which no other in our language is 
comparable. — Charleston Medical Journal. 

No work has ever achieved or maintained a more 
deserved reputation. — Va. Med. and Surg. Journal, 



WHAT TO OBSERVE 
AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. 

Published under the authority of the London Society for Medical Observation. A new American, 
from the second and revised London edition. In one very handsome volume, royal 12mo., extra 
cloth. $1 00. 

To the observer who prefers accuracy to blunders 1 One of the finest aids to a young practitioner we 
and precision to carelessness, this little book is in- have ever seen. — Peninsular Jou\ icint. 

valuable. — N. If. Journal of Medicim. I 



30 BLANCHARD & LEA'S MEDICAL 

New and much enlarged edition— (Just Issued.) 
WATSON (THOMAS), M. D., &c, 

Late Physician to the Middlesex Hospital, &c. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. 

Delivered at King's College, London. A new American, from the last revised and enlarged 

English edition, with Additions, by D. Francis Condie, M. D., author of "A Practical Treatise 

on the Diseases of Children, 1 ' &c. With one hundred and eighty. rive illustrations on wood. In 

one very large and handsome volume, imperial octavo, of over 1200 closelv printed pages in 

small type ; the whole strongly bound in leather, with raised bands. Price S4 25. 

That the high reputation of this work might be fully maintained, the author has subjected it to a 

thorough revision ; every portion has been examined' with the aid of the most recent researches 

in pathology, and the results of modern investigations in both theoretical and practical subjects 

have been carefully weighed and embodied throughout its pages. The watchful scrutiny of the 

editor has likewise introduced whatever possesses immediate importance to the American physician 

in relation to diseases incident to our climate which are little known in England, as well as those 

points in which experience here has led to different modes of practice ; and he has also added largely 

to the series of illustrations, believing that in this manner valuable assistance may be convej'ed to 

the student in elucidating the text. The work will, therefore, be found thoroughly on a level with 

the most advanced state of medical science on both sides of the Atlantic. 

The additions which the work has received are shown by the tact that notwithstanding an en- 
largement in the size of the page, more than two hundred additional pages have been necessary 
to accommodate the two large volumes of the London edition (which sells at ten dollars), within 
the compass of a single volume, and in its present form it contains the matter of at least three 
ordinary octavos. Believing it to be a work which should lie on the table of every physician, and 
be in the hands of every student, the publishers have put it at a price within the reach of all, making 
it one of the cheapest books as yet presented to the American profession, while at the same time 
the beauty oi its mechanical execution renders it an exceedingly attractive volume. 

The fourth edition now appears, so carefully re- The lecturer's skill, his wisdom, his learning, are 
vised, as to add considerably to the value of a book equalled by the ease of his graceful diction, his elo- 
already acknowledged, wherever the English Ian- qaence, and the far higher qualities of candor, of 
guage is read, to be beyond ail comparison the best courtesy, of modesty, and of generous appreciation 
systematic work on the Principles and Practice of of merit in others. May he long remain to instruct 
Physic in the whole range of medical literature, us, and to enjoy, in the glorious sunset of his de- 
Every lecture contains proof of the extreme anxiety dining vearsj the honors, the confidence and love 
of the author to keep pace wiclvhe advancing know- gained during his useful life.— N. A. Med-Chir. 
ledge of the day, and to bring the results of the Review, July, 1S5S. 

labors, not onlv of phvsicians, but of chemists and ___ . „ , , , . , 

histologists. before his readers, wherever they can Watson's unrivalled, perhaps unapproachable 
be turned to useful account. And this is done with work on Practice— the copious additions made to 
such a cordial appreciation of the merit due to the which (the fourtn edition) hare given it all the no- 
industrious observer, such a generous desire to en- velt ? and rrmch of the interest ot^a new book.— 
courage younger and rising men, and such a candid Charleston Med. Journal, Jul) - , ie5S. 



acknowledgment of his own obligations to them. 



Lecturers, practitioners, and students of medicine 



tnat one scarcely knows whether to admire most the will eq uallv hail the reappearance of the work of 

pure, simpie, forcible English— tne vast amount of Dr. Watson in the form of a new— a fourth— edition, 

useful practical information condensed into the \y e mereiv do justice to our own feelings, and, we 

Lectures— or the manly, kind-hearted, unassuming are sure, 6Y the whole profession, if we^thank him 

character of the lecturer shining through his work. for having. in the trouble and turmoil of a large 

—London Med. Times and Gazette, Oct. 31, ls57. practice, made leisure to supply the hiatus caused 

Thus these admirable volumes come "rjefore the ! by the exhaustion of the publisher's stock of the 

profession in their fourth edition, abounding in those third edition, which has been severely felt for the 

distinguished attributes of moderation, judgment, last three years. For Dr. Watson has not merely 

erudite cultivation, clearness, and eloquence, with caused the lectures to be reprinted, but scattered 

which they were from the first invested, but yet through the whole wOrk we find additions or altera- 

richer than before in the results of more prolonged tions which prove that the author has in every way 

observation, and in the able appreciation of the' sought to bring up his teaching to the level of the 

latest advances in pathology and medicine by one most recent acquisitions in science. — Brit, and For. 

of the most profound medical thinkers of the day. — Medico-Chir. Review, Jan. 1S5S. 
London Lancet, Nov. 14, 1657. 



WALSHE (W. H.) s M. D., 

Professor of the Principles and Practice of Medicine in University College, London. &c. 

A PRACTICAL TREATISE ON DISEASES OF THE LUNGS ; 'including 

the Principles of Physical Diagnosis. A new American, from the third revised and much en- 
larged London edition. In one vol. octavo, of 468 pages. (Just Issued, June, 1860.) $2 25. 
The present edition has been carefully revised and much enlarged, and may be said in the main 
to be rewritten. Descriptions of several diseases, previously omitted, are now introduced; the 
causes and mode of production of the more important affections, so far as they possess direct prac- 
tical significance, are succinctly inquired into ; an effort has been made to bring the description ol 
anatomical characters to the level of the wants of the practical physician ; and the diagnosis and 
prognobis of each complaint are more completely considered. The sections on Treatment and 
the Appendix (concerning the influence of climate on pulmonary disorders), have, especially, been 
largely extended. — Author's Preface. 
&*# To be followed by a similar volume on Diseases of the Heart and Aorta. 



WILSON (ERASMUS), F. R. S., 

Lecturer on Anatomy, Lundon. 

TEE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third 

American, from the last revised and enlarged English edition. Modified and rearranged, by 
William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania. In one 
large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. §2 00. 



AND SCIENTIFIC PUBLICATIONS 



31 



New and much enlarged edition — (Just Issued.) 
WILSON (ERASMUS), F. R. S. 
A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- 
vised American, from the last and enlarged English Edition. Edited by W. H. Gobeecht, M. D., 
Professor of Anatomy in the Pennsylvania Medical College, &c. Illustrated with three hundred 
and ninety-seven engraving's on wood. In one large and exquisitely printed octavo volume, of 
over 600 large pages; leather. $3 25. 

The publishers trust that the well earned reputation so long enjoyed by this work will be more 
than maintained by the present edition. Besides a very thorough revision by the author, it has been 
most carefully examined by the editor, and the efforts of both have been directed to introducing 
everything which increased experience in its use has suggested as desirable to render it a complete 
text-book for those seeking to obtain or to renew an acquaintance with Human Anatomy. The 
amount of additions which it has thus received may be estimated from the fact that the present 
edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged 
page requisite to keep the volume within a convenient size. The author has not only thus added 
largely to the work, but he has also made alterations throughout, wherever there appeared the 
opportunity of improving the arrangement or style, so as to present every fact in its most appro- 
priate manner, and to render the whole as clear and intelligible as possible. The editor has 
exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the 
number of illustrations, of which there are about one hundred and fifty more in this edition than 
in the last, thus bringing distinctly before the eye of the student everything of interest or importance. 



It may be recommended to the student as no less 
distinguished by its accuracy and clearness of de- 
scription than by its typographical elegance. The 
wood-cuts are exquisite. — Brit, and For. Medical 
Review. 

An elegant edition of one of the most useful and 
accurate systems of anatomicai science which has 
been issued from the press The illustrations are 
really beautiful. In its style the work is extremely 
concise and intelligible. No one can possibly take 
up this volume without being struck with the great 



beauty of its mechanical execution, and the clear- 
ness of the descriptions which it contains is equally 
evident. Let students, by all means examine tne 
claims of this work on their notice, before they pur- 
chase a text-book of the vitally important science 
which this volume so fully and easily unfolds.— 
Lancet. 

We regard it as the best system, now extant for 
students. — Western Lancet. 

It therefore receives our highest commendation. — 
Southern Med. and Surg. Journal. 



BY THE SAME AUTHOR. (Just Issued.) 

ON DISEASES OF THE SKIN. Fourth and enlarged American, from the last 
and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75. 



The writings of Wilson, upon diseases of the skin, 
are by far the most scientific and practical that 
have ever been presented to the medical world on 
this subject. The present edition is a great improve- 
ment on all its predecessors. To dwell upon all the 
great merits and high claims of the work before us, 
seriatim^ would indeed be an agreeable service; it 
would be a mental homage which we could freely 
offer, but we should thus occupy an undue amount 
of space in this Journal. We will, however, look 



at some of the more salient points with which it 
abounds, and which make iiincompura uiy superior in 
excellence to all other treatises on the subject of der- 
matology. No mere speculative views are allowed 
a place in this volume, which, without a doubt, will, 
for a very long period, be acknowledged as the chief 
standard work on dermatology. The principles of 
an enlightened and rational therapeia are introduced 
on every appropriate occasion. — Am. Jour. Med. 
Science, Oct. 1857. 



ALSO, WOW READY, 

A SERIES OF PLATES ILLUSTRATING- WILSON ON DISEASES OF 

THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve are exquisitely 
colored, presenting the Normal Anatomy and Palhology of the Skin, and containing accurate re- 
presentations of about one hundred varieties of disease, most of them the size of nature. Price 
in cloth $4 25. 

In beauty of drawing and accuracy and finish of coloring these plates will be found equal to 
anything of the kind as yet issued in this country. 

The plates by which this edition is accompanied 
leave nothing to be desired, so far as excellence of 
delineation and perfect accuracy of illiibtration are 
concerned. — Medico-Chirurgical Review. 



We have already expressed our high appreciation 

of Mr. Wilson's treatise on Diseases of the Skin. 
The plates are comprised in a separate volume, 
which we counsel all those who possess the text to 
purchase. It is a beautiful specimen of color print- 
ing, and the representations of the various forms of 
skin disease are as faithful as is possible in plates 
of the size.— Bosoon Med. and Surg. Journal Arril 
8,1858. "'~ F 



Of these plates it is impossible to speak too highly 
The representations of the various forms of cutane- 
ous disease are singularly accurate, and the color- 
ing exceeds almost anything we have met with in 
point of delicacy and finish.— British and Foreign 
Medical Review. 

BY THE SAME AUTHOR. 

ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON 

SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with 
four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. 52 25 

BY THE SAME AUTHOR. 

HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- 
tion and Management. Second American, from the fourth London edition. One neat volume, 
royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. $1 00 ; paper cover, 
75 cents. 



WHITEHEAD ON THE CAUSES AND TREAT- 
MENT OF ABORTION AND STRRIL1TY. 



Second American Edition. In one volunu- 
vo extra cloth, pp. SOS. $1 75. 



32 



BLANCHARD & LEA'S MEDICAL PUBLICATIONS. 



ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE 

MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis. In one 
handsome octavo volume, of nearly 600 pages. {Just Issued, June, 1660.) $3 00. 
The momentous questions discussed in this volume have perhaps not hitherto been so ably and 
elaborately treated. Dr. Winslow's distinguished reputation and long experience in everything re- 
lating to insanity invest his teachings with the highest authority, and in this carefully considered 
volume he has drawn upon the accumulated resources of a life of observation. His deductions 
are founded on a vast number of cases, the peculiarities of which are related in detail, rendering 
the work not only one of sound instruction, but of lively interest; the author's main object being 
to point out the connection between organic disease and insanity, tracing the latter through all its 
stages from mere eccentricity to mania, and urging the necessity of early measures of prophylaxis 
and appropriate treatment. A subject of greater importance to society at large could scarcely be 
named; while to the physician who may at any moment be called upon for interference in the most 
delicate relations of life, or for an opinion in a court of justice, a work like the present may be con- 
sidered indispensable. 

The treatment of the subject may be gathered from the following summary of the contents : — 
Chapter I. Introduction. — II. Morbid Phenomena of Intelligence. III. Premonitory Symptoms 
of Insanity. — IV. Confessions of Patients after Elecovery. — V. State of the Mind during Re- 
covery. — VI. Anomalous and Masked Affections of the Mind. — VII. The Stage of Consciousness. 
— VI11. Stage of Exaltation. — IX. Stage of Mental Depression. — X. Stage of Aberration. — XI. 
Impairment of Mind. — XII. Morbid Phenomena of Attention. — XIII. Morbid Phenomena of 
Memory. — XIV. Acute Disorders of Memory. — XV. Chronic Affections of Memory. — XVT. 
Perversion and Exaltation of Memory. — XVII. Psychology and Pathology of Memory. — XVIII. 
Morbid Phenomena of Motion. — XIX. Morbid Phenomena of Speech. — XX. Morbid Phenomena 
of Sensation. — XXI. Morbid Phenomena of the Special Senses. — XXII. Morbid Phenomena of 
Vision, Hearing, Taste, Touch, and Smell. — XXIII. Morbid Phenomena of Sleep and Dreaming. 
— XXIV. Morbid Phenomena of Organic and Nutritive Life. — XXV. General Principles of Pa- 
thology, Diagnosis, Treatment, and Prophylaxis. 



WEST (CHARLES), M. D., 

Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for 

Sick Children, &c. 

LECTURES ON THE DISEASES OF WOMEN. Now complete in one hand- 

some octavo volume, extra cloth, of about 500 pages ; price $2 50. 
Also, for sale separate, Part II, being pp. 309 to end, with Index, Title matter, 
&c, 8vo., cloth, price $1. 



and children is not to be found in any country. — 
Southern Med. and Surg. Journal, January 1858. 

We gladly recommend his Lectures as in the high- 
est degree instructive to all who are interested in 
obstetric practice. — London Lancet. 

We have to say of it, briefly and decidedly, that 
it is the best work on the subject in any language; 
and that it stamps Dr. West as the facile princeps 
of British obstetric authors. — Edinb. Med. Joum. 



We must now conclude this hastily written sketch 
with the confident assurance to our readers that the 
work will well repay perusal. The conscientious, 
painstaking, practical phy sician is apparent on every 
page. — N. Y. Journal of Medicine, March, 1858. 

We know of no treatise of the kind so complete 
and yet so compact. — Chicago Med. Journal, Janu- 
ary, 1858. 

A fairer, more honest, more earnest, and more re- 
liable investigator of the many diseases of women 

BY THE same author. (Now Ready.) 

LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. 

Third American, from the fourth enlarged and improved London edition. In one handsome 
octavo volume, extra cloth, of about six hundred and fifty pages. $2 75. 

The continued favor with which this work has been received has stimulated the author to ren- 
der it in every respect more complete and more worthy the confidence of the profession. Con- 
taining nearly two hundred pages more than the last American edition, with several additional 
Lectures and a careful revision and enlargement of those formerly comprised in it, it can hardly 
fail to maintain its reputation as a clear and judicious text-book for the student, and a safe and 
reliable guide for the practitioner. The fact stated by the author that these Lectures ' ; now embody 
the results of 900 observations and 288 post-mortem examinations made among nearly 30,000 
children, who, during the past twenty- years, have come under my care," is sufficient to show their 
high practical value as the result of an amount of experience which few physicians enjoy. 

diseases it omits to notice altogether. But those 
who know anything of the present condition of 
paediatrics will readily admit that it would be next 
to impossible to effect more, or effect it better, than 
the accoucheur of St. Bartholomew's has done m a 
single volume. The lecture (XVI.) upon Disorcers 
of the Mind in children is an admirable specimen of 
the value of the later information conveyed in the 
Lectures of Dr. Charles West. — London Lancet, 
Oct. 22, 1859. 

Since the appearance of the first edition, about 
eleven years ago, the experience of the author has 
doubled ; so that, whereas the lectures at first were 
founded on six hundred observations, and one hun- 
dred and eigniy dissections made among nearly four- 
teen thousand children, they now embody the results 
of nine hundred observations, and two hundred and 
eighty-eight post-mortem examinations made among 
nearly thirty thousand children, who, during the 
past twenty years, have been under his care. — 
British Med. Journal, Oct. 1, 1859. 



The three former editions of the work now before 
us have placed the author in trie foremost rank of 
those physicians who have devoted special attention 
to the diseases of early life We attempt no ana- 
ly sis of this edition, but may refer the reader to some 
of the chapters to which the largest additions have 
been made — those on Diphtheria, Disorders of the 
Mind, and Idiocy, for instance— as a prooi that the 
work is really a new edition ; not a mere reprint. 
In its present shape it will be found of the greatest 
possible service in the every-day practice of nine- 
tenths of the profession. — Med. Times and Gazette, 
London, Dec. 10, 1859. 

All things considtred, this book of Dr. West is 
by far the "best treatise in our language upon such 
modifications of morbid action and disease as are 
witntssed when we have to deal with infancy and 
childhood. It is true that it confines itself to such 
disorders as come wichin the province of the phy- 
sician, and even with respect to these it is unequal 
as regards minuteness of consideration, and some 

BY THE SAME AUTHOR. 

AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- 
ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. 



LIBRARY OF CONGRESS £ 



029 827 752 9 




